• Archives of Plastic Surgery
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• v.48 no.1
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• pp.44-48
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• 2021

Previously reported nipple-areolar complex reconstruction (NAR) methods involve multiple incisions and wide skin redraping, which increase retraction forces and heighten the risk of nipple-areolar complex (NAC) flattening. We introduce a NAR method using the long V-Y advancement technique that can overcome these disadvantages. A V-shaped flap is designed with the width of the flap base 4-5 mm larger than the diameter of the normal nipple. The flap length is designed to be at least 2.5 times its width. Dissection is performed to the top of the artificial dermal matrix or muscle layer. The nipple is constructed with the same projection as the contralateral side by folding the elevated flap. The tip of the elevated flap is apposed in the middle of the donor defect to minimize the deformity during donor site closure. A 3-point skin suture is applied to the upper third of the folded flap to mold its shape. Using this long V-Y advancement technique, we successfully decreased skin tension in NAC flaps and improved the maintenance of reconstructed nipple projection. The long V-Y advancement technique provides an easy, simple NAR method, effectively maintaining longer nipple projections and reducing breast deformities, especially in Asian women with relatively large nipples.

• Archives of Craniofacial Surgery
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• v.22 no.6
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• pp.341-344
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• 2021

Reconstruction of submental defects is a challenge that needs to be approached carefully, since many important anatomical structures are located in this small space. Both aesthetic and functional outcomes should be considered during reconstruction. In this report, we describe a case where a superficial branch of the transverse cervical artery (STCA) perforator propeller flap was applied for coverage of the submental area. An 85-year-old woman presented with a 3-cm ovoid mass on her submental area. We covered the large submental defect with a STCA rotational flap in a 180° propeller pattern. The flap survived well without any complications at 1 year of followup. A STCA propeller flap is a useful surgical option in reconstruction for defect coverage of the submental area.

• Archives of Plastic Surgery
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• v.49 no.5
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• pp.696-700
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• 2022

We performed distal bypass and free flap transfer in a single-stage operation to repair an extensive soft tissue defect in an ischemic foot of an 84-year-old woman. The nutrient artery of the free flap was anastomosed to the bypass graft in an end-to-side manner. Subsequently, the bypass graft became occluded on several occasions. Although intravascular and surgical interventions were performed each time, the bypass graft eventually became completely occluded. However, despite late occlusion of the nutrient artery, the free flap has remained viable and the patient is ambulatory. The time required for a transplanted free flap to become completely viable without a nutrient artery is likely longer for an ischemic foot compared with a healthy foot. However, the exact period of time required is not known. A period of month was required in our patient. We report this case to help clarify the process by which a free flap becomes viable when applied to an ischemic foot.

• Journal of Veterinary Clinics
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• v.40 no.2
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• pp.152-157
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• 2023

A two-year-old, spayed female, Bichon Frise, was referred for severe corneal edema and corneal ulcer in the left eye (OS). The cornea had gradually swelled over one week after phacoemulsification performed a month prior, and that was refractory to 5% sodium chloride eye drop instillation or temporary partial tarsorrhaphy. A complete ophthalmic examination was performed. Severe corneal edema with intrastromal bullae and moderate anterior chamber flare was found on slit-lamp biomicroscopy in the OS, which obstructed the fundus examination. Corneal thickness was measured using high-resolution ultrasound biomicroscopy. The thickness of the OS cornea was 2.74 mm. The "letter-box" conjunctival flap was planned. Dorsal and ventral superficial keratectomy followed by a hood conjunctival flap was performed. Topical and systemic antibiotics and 5% sodium chloride eye drops were prescribed. Decreased corneal thickness was observed at one week, two weeks, and two months postoperatively (1.53 mm, 1.32 mm, and 0.92 mm, respectively). There were no postoperative complications, such as ocular discomfort or recurrent corneal ulcers. The "letter-box" conjunctival flap, a type of superficial keratectomy and conjunctival advancement hood flap, effectively relieved the severe irreversible corneal edema. This could be a simple but effective surgical intervention for patients with endothelial cell damage especially after phacoemulsification.

• Archives of Plastic Surgery
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• v.50 no.2
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• pp.153-155
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• 2023

The vascular anatomy of the deep inferior epigastric artery perforator (DIEP) flap has been well studied in the planning for autologous breast reconstruction. Preoperative imaging with computed tomography angiography (CTA) provides accurate assessment of this vascular anatomy, which varies widely across patients. Several papers to date have described their encounter with an anomalous "epiperitoneal" or "peritoneo-cutaneous" perforator during flap harvest, a perforator that pierces the posterior rectus sheath from a peritoneal origin, to traverse rectus abdominis and supply the DIEP flap integument. In the course of over 3,000 CTA assessments of the vascular anatomy of the abdominal wall, we have encountered dominant peritoneo-cutaneous perforators in 1% of cases, and smaller perforators seen in many more cases, approaching 5% of cases. With increasing sensitivity of imaging, we also describe a unique case of multiple large bilateral peritoneo-cutaneous perforators, and present these findings in the context of DIEP flap harvest. It is critical to recognize these peritoneo-cutaneous perforators preoperatively to avoid mistaking them for a DIEP during the raising of a DIEP flap. The routine use of preoperative CTA enables the safe identification of individual vascular anatomy, including significant peritoneo-cutaneous perforators.

• Archives of Craniofacial Surgery
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• v.24 no.4
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• pp.159-166
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• 2023

Background: Free tissue transfer is the preferred method of reconstructing head and neck defects, with a success rate of approximately 95%. Although flap failure is uncommon, it has a major impact on patient morbidity and diminishes quality of life, making it is important to investigate the causes of flap failure. Methods: This retrospective chart review analyzed patients who underwent free tissue transfer during head and neck reconstruction at a single institution between 2016 and 2021. Results: During the study period, 58 patients underwent 60 free flap procedures. Revision surgery was needed in 14 patients. Subsequent free flap surgery was performed in one patient, and three free flaps (5%) could not be salvaged. Cardiovascular disease was significantly associated with flap failure, and venous congestion (thrombosis) was the most common reason for revision surgery. Conclusion: Cardiovascular disease clearly emerged as a factor related to the failure of free flap surgery, and this issue warrants particular attention in patients for whom free tissue transfer is planned.

• Archives of Craniofacial Surgery
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• v.24 no.6
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• pp.260-265
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• 2023

Background: The traditional nasolabial V-Y advancement flap is widely used for midface reconstruction, particularly for the lower third of the nose and upper lip, as its color and texture are similar to these areas. However, it provides insufficient tissue to cover large defects and cannot restore the nasal convexity, nasal ala, and adjacent tissues. The purpose of this study is to investigate the modified nasolabial V-Y advancement flap with extension limbs the along alar crease for the reconstruction of complex midface defects. Methods: A retrospective analysis of 18 patients, who underwent reconstruction with the modified nasolabial V-Y advancement flap, was performed between September 2014 and December 2022. An extension limb was added along the alar crease, adjacent to the defect area, and was hinged down as a transposition flap at the end of the advancement flap. Results: The extension limb along the alar crease successfully covered large and complicated defects, including those of the ala, the alar rim, the alar base, the nostrils, and the upper lip, with minor complications. Conclusion: The alar crease is a good donor site for the reconstruction of large and complex nasal and upper lip defects.

• Archives of Plastic Surgery
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• v.50 no.6
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• pp.568-572
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• 2023

Cutaneous squamous cell carcinoma (CSCC) overlying an arteriovenous fistula (AVF) is rare and presents unique challenges. This case report describes a method of fistula preservation after CSCC excision using a flow-through venous free flap. The saphenous vein of the venous flap was used as flow-through segment for AVF preservation. The flap was inserted along the dorsal aspect of the forearm wound and microvascular anastomosis of the arterial inflow was completed using a vein just proximal to the radiocephalic fistula anastomosis. Venous outflow was established by creating an end-to-end vascular anastomosis between the cephalic vein and the greater saphenous vein. A separate subcutaneous vein was used to provide a low-pressure outflow for the flap to avoid congestion. This case demonstrates an option for AVF preservation that has not been previously described. It also highlights the importance of a multidisciplinary approach for the safe treatment of CSCCs overlying AVFs.

• Archives of Plastic Surgery
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• v.38 no.6
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• pp.747-754
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• 2011

Purpose: The Abbe flap procedure has been used to correct disharmony of the upper and lower lips as well as for making a philtrum for patients with secondary cleft lip deformities. But the Abbe flap procedure adds two scars in addition to the prior operative scar on the upper lip. This study was conducted to determine the treatment outcomes of esthetic subunit excision of the scar on the philtrum and Abbe flap coverage for correction of cleft lip deformities with photogrammetric analysis. Methods: This study investigated a total of 11 patients with cleft lip deformities who underwent scar excision with Abbe flap coverage, and the patients were followed up for at least 6 months. Under general anesthesia, a mushroom-shaped Abbe flap was drawn on the lower lip with a width of 8 mm and a height 1~2 mm longer than that of the philtral midline. The epidermis and dermis of the scar on the upper lip were excised. In the cases with alar base depression, the orbicularis oris muscle was split vertically and transposed to the alar base. The Abbe flap was harvested as a pedicled flap containing a small amount of muscle and this was rotated 180-degree to be inserted into the upper lip. Mucosa, muscle, subcutaneous tissue and skin were closed in layers. The flap was divided at the 7~14 postoperative day. The postoperative outcomes were evaluated by using photogrammetric analysis. Three indices were measured from the standard clinical photographs taken before and after the surgery. For anthroposcopic assessment, observers described the postoperative outcomes using an ordinary scale method. Results: The postoperative values obtained in the photogrammetric analysis showed improvement as compared with the preoperative ones. Improved anthroposcopic outcomes were also noted. Conclusion: Scar excision and Abbe flap coverage were proven to be effective in improving protrusion and the height of the upper lip, the scar of the upper lip and the symmetry of Cupid's bow and the philtral column, as well as formation of the philtral dimple.

• Archives of Plastic Surgery
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• v.35 no.5
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• pp.527-532
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• 2008

Purpose: Transverse type or volar oblique type of defect of thumb tip can be covered by Moberg flap or second toe pulp free flap. We compared these two methods in functional result, patients' satisfaction, and sensation, etc. to find a better way to cover the defect of the thumb tip. Methods: From 2003 to 2006, we chose the patients randomly with preoperative pictures. The patients had the defect of the thumb tip which is either transverse or volar oblique type. The 6 patients were treated with Moberg flap and other 6 patients were treated with second toe pulp free flap. We have analyzed the results by 2 point discrimination, side pinching power test, pulp to pulp pinching power test, pain scales (visual analogue scale), satisfaction scales of the patients (functional and aesthetic), the degree of the range of motion, etc. Results: All flaps survived without any complications. In the cases of Moberg flaps, the value of static 2 point discrimination test was 5.6 mm, and the value of moving 2 point discrimination test was 4.8 mm. In the cases of second toe pulp free flaps, the values were 9.6 mm and 9.3 mm. In the cases of Moberg flaps, the value of the Side pinch power test was 6.6 kg, 4.4 kg. In the case of second toe pulp free flaps, the values were 4.8 kg and 2.5 kg. The value of aesthetic satisfaction scale of the patients in Moberg flaps was 5.6, the value of functional satisfaction scale of the patients was 3.6. In cases of second toe pulp free flaps, the values were 5.6 and 3.6. The active range of motion of Interphalangeal joint in the cases of Moberg flaps was 46.6 degree, and the active range of motion of metacarpophalangeal joint was 55 degree, in the cases of second toe pulp free flaps, the values were 36.6 degree and 59 degree. Conclusion: As a result, when the defect of the thumb tip is transverse or volar oblique type, we suggest that the operators choose Moberg flap to cover the defect of the thumb tip.