World Journal of Plastic Surgery
Volume:10 Issue: 3, Sep 2021

Thigh-based, groin-based and lateral-thoracic-based flaps are available for microsurgical hand resurfacing – which is the best? 

BestBETS methodology was used to systematically evaluate the advantages and disadvantages. PubMed, EMBASE and Cochrane databases were searched up until Sep 2020, using the search strategy: hand re-surfacing, free-flap, groin-flap, thigh-flap, lateral thoracic-flap, advantages, and disadvantages. 

Overall, 31 papers were identified which were used to synthesize the discussion and conclusions. 

Thigh-based anterolateral thigh (ALT) flaps offer the greatest versatility.

Many different flaps had been described to cover exposed bone in fingertip amputations and injuries. The variants of VY advancement flap, by far the simplest, had proven to render good functional and aesthetic outcome. We aimed to revisit and compare the various VY advancement flaps in fingertip reconstruction.

PubMed [MEDLINE] database was searched for VY advancement flap in fingertip reconstruction. Demographic and outcome data were extracted from relevant studies and comparative analysis was made. Patients with fingertip amputations undergoing reconstruction by either Kutler of Atasoy flaps in our institute, were assessed for sensory recovery, cold intolerance, joint’s range of motion, and aesthetic outcomes and results were analysed.

Among the 744 articles, 32 citations went full text review and were included, while data of 13 articles were tabulated. Weighted mean of 2PD in Kutler and Atasoy estimated to be 6 and 7.5 mm respectively. Hook nail deformity was in 29% and 35%, pain was present in 71% and 30% patients, in Kutler and Atasoy flaps respectively. Forty fingertips with Allen type II/III were reconstructed. Sensory outcomes of Atasoy flap and Kutler flaps were better than the previous study results. Four patients had cold intolerance. All patients achieved satisfactory aesthetic outcome.

Over time, VY advancement flap have been successfully used for reconstruction of Allen type II-IV fingertip amputations, as suggested by the good sensory, functional and aesthetic outcomes.

The anterolateral thigh (ALT) flap is one of the fasciocutaneous flaps in the thigh region based on the septocutaneous or musculocutaneous perforators derived from the lateral circumflex femoral artery (LCFA). This cadaveric study aimed to explore the variability of ALT flap anatomy.

Ten ALT flaps were dissected (2016-20117, Mashhad Legal Medicine Organization) in 10 fresh cadavers (7 males and 3 females). Flaps were marked in a 15 cm area centered on the middle point of a line drown from anterior superior iliac spine to the lateral surface of the patella. Dissection began by searching the skin perforators and then continued along the pathway of the vascular pedicle.

The average distance of ASIS-Patella was 44.6 cm. The mean number of skin perforators was 2.4 (ranged from 0 to 4). In one case, we did not find any skin perforator. The majority of skin perforators were musculocutaneous from descending branch of LCFA (66.7%) and the remaining were septocutaneous (33.3%). The mean length of vascular pedicle was 10.17 cm. The average diameter of vascular pedicle was 2.78 mm for the artery and 3.79 mm for the vein. The average time of flap harvesting was 85.3 min (ranged from 50 to 125 min).

The skin perforators supplying the ALT flap showed significant variability in number, location and course. The cadaveric study could enhance the anatomic knowledge and operative skills of ALT flap harvesting.

We aimed to assess the incidence of bad split fractures during Bilateral Sagittal Split Osteotomy (BSSO) mandibular setback surgery using Dal Pont and Hunsuck techniques.

All healthy adults with skeletal class III discrepancy, who were candidates for mandibular setback surgery were enrolled in this randomized clinical trial in the Maxillofacial Surgery Department of Qaem Hospital, Mashhad, Iran; from 2018-2020. These patients were randomly divided into two equal groups; one group underwent BSSO using Dal Pont osteotomy while the Hunsuck osteotomy was employed for the other group. A bad split fracture which identified through intra-operative clinical and postoperative radiographic examination was the outcome variable. The significance level was set at 0.05 using SPSS 16.

Overall, 104 consecutive patients, comprising of 52 (50%) males with an average age of 23.09±3.08 were recruited. The average duration of osteotomy and splitting was reported to be 22.74±3.06 min. 10 bad split fractures (9.62%) were observed; 7 of which occurred in the Dal Pont group and 3 in the Hunsuck group. However, this difference was not significant. In 80% of the cases, bad split osteotomy occurred in the proximal segment, while this finding was identified in the distal segment in 20% of cases. The average duration of osteotomy and splitting was significantly longer in the Dal Pont group (P<0.001).

The duration of osteotomy and splitting is much shorter when the Hunsuck technique is employed, and the incidence of unfavorable fractures is also less compared to the Dal Pont osteotomy technique.

We aimed to compare inflammatory and intercellular transcription responses induced by surface textured (ST) implants versus foam covered (FC) silicone implants placed on the dorsal aspect of rats.

We utilized 80 female rats of the Wistar lineage. The rats were divided into four subgroups of 20 with one type of implant placed in the dorsum per rat. Analysis was carried out on peri-implant capsules at 90 d and at 180 d post-surgery with microscopic evaluation of inflammatory and immuno-histochemical response of NF-κB-p65 and α-SMA in fibroblasts. This study was carried out at the Evangelical Faculty of Parana and at the Ivo Pitanguy Institute, Brazil in 2015.

The FC exhibited higher levels of acute and chronic inflammation on evaluation in both time frames. The capsule surrounding the ST implants was significantly thicker with well-organized collagen fibres. NFκB-p65 expression in the capsule surrounding the FC implant was more pronounced. There was higher and more significant α-SMA expression in the capsules of the surface textured (ST) silicone implants compared to the foam-covered (FC) silicone implants.

Activation of NFκB-p65 plays a key role in the evolution of capsule formation and maintenance of inflammation by regulating the healing process. Similarly, higher and more prolonged levels of inflammation (increased NF-κB-p65 results in increased inflammation) and lower α-SMA (higher α-SMA is protective against capsular contracture) did not directly translate to a thicker capsule and ultimately, capsular contracture in foam covered silicone implants.

Iranian people celebrate the last Wednesday of the year also known as Chahar Shambeh Soori (CSS) using low explosive pyrotechnics classified as fireworks. Mishaps and accidents are common and maxillofacial fractures may occur which have a negative impact on the quality of life. This study aimed to assess maxillofacial fractures (fx) caused by explosive agents.

This cross-sectional descriptive study assessed 283 patients suffering maxillofacial fxs caused by explosive agents during CSS ceremonies between 2009 and 2019 referred to our craniomaxillofacial (CMF) surgery center. The data assessed included age, sex, cause, type, site, and severity of injury, fracture patterns, treatment modalities, and complications. All maxillofacial injuries were evaluated and treated by Craniomaxillofacial staff surgeons.

Among 283 patients, 72.8% (206) and 27.2% (77) were men and women, respectively. The mean age of patients was 17.35 years. The most common maxillofacial fracture was in the mid-face; with the distribution of fractures being: 39.9% zygomatic fractures, 32.1% nasal bone fractures, 63.2% dentoalveolar fracture, 43.1% Le Fort (Le Fort I, Le Fort II, Le Fort III), 31.4% orbital, and 43.1% mandible fractures. The most frequent type of treatment was Open Reduction and Internal Fixation (ORIF) (77.4%).

The most common site of maxillofacial fractures and most frequent treatment used were similar to military or ballistic injuries. ORIF was common treatment.

Surgical antibiotic prophylaxis has been widely used for prevention of surgical site infections (SSI’s). World Health Organization (WHO) global guidelines strongly recommend the administration of pre-operative prophylactic antibiotic, depending on the type of surgery, to reduce SSI’s. However, within Gulf Cooperation Council (GCC) countries, antibiotic resistance has been rising due to unregulated prescribing practice. We aimed to assess adherence to local/international guidelines in the plastic surgery unit of Salmaniya Medical Complex.

This study was a retrospective review of adults’ undergoing plastic surgery between the dates of 1st of January 2019 to 30th of April 2019. Recommendations and guidelines were provided by South Australian Guidelines for Surgical Antimicrobial Prophylaxis, NHS Greater-Glasgow Foundation Trust.  Salmaniya Medical Complex Guidelines were also taken into consideration. This was followed by an implementation of standardized guidelines and a re-assessment period for another four months.

There were 106 patients who met the inclusion/exclusion criteria throughout the primary cohort. With respect to choice and dose of antibiotics, only 21 (19.8%) of the procedures were adherent to global/local guidelines. Similarly, only 11.5% of those cases have met the recommended timing for pre-operative antibiotic administration. After the implementation period, adherence to guidelines regarding choice and time of antibiotic administration has increased to 36.8% and 32.6% respectively. SSI decreased from 1.8% to 0.08%.

Practice in SMC in plastic surgery pre-operative antibiotic prophylaxis shows poor compliance to both local and international guidelines in terms of choice, dose, and time of administration. We were able to significantly improve adherence to international/local practice in both areas by implementing an integrated protocol in liaison with the medical staff involved in the plastic surgery unit and operating theatres.

Sensory recovery and durability of the flap is the primary goal of heel soft tissue reconstruction. From the different options, the choice of the flap depends on the size of the defect, its location, and the availability of the donor area.

In this retrospective study, 40 patients having heel defects were included from Jan 2016 to Dec 2018 in which different flaps were used for the reconstruction. The outcome was evaluated in terms of flap survival, recovery of sensation, the durability of coverage, and functional denouement. We also analysed the outcome between neuropathic and non-neuropathic ulcers of the heel.

Out of 40 patients’ medial plantar artery islanded flap was performed in eight cases, extended reverse sural flap in 16 cases, islanded reverse sural flap in six cases, local flaps in six cases, cross-leg flap in two cases, and free Latissimus Dorsi muscle flaps with Skin Graft cover in two cases. The patients were observed for a mean follow-up time of 15 months (12-20 months). Only two flaps showed marginal necrosis as an immediate complication. The majority of the flaps were tenacious in the follow-up period except for the six flaps that developed delayed ulceration. Return of protective sensation (P=0.006) and mean American Orthopaedic Foot and Ankle Society subjective score (P=0.025) was significantly higher in the non-neuropathic ulcer group.

Locoregional flaps can cover most of the heel defects with a satisfactory outcome. The functional outcome was lower in the reconstructed neuropathic heel ulcer group.

Hypospadias is one of the most common congenital anomalies of the external genitalia of boys. No single technique can be recommended for the repair of hypospadias in its various forms. We aimed to compare modify meatal advancement glandular with release chordi versus Snodgrass surgical methods in the repair of distal hypospadias.

In this study, conducted from Apr 2018 to the end of Sep 2020, all boys who underwent one of the two methods of Snodgrass and modify meatal advancement glanuplasty with release chordi in Imam Khomeini and Abuzar Hospitals of Ahvaz, Southern Iran, were enrolled.

Forty-five patients underwent Snodgrass (group S) and 55 patients underwent modified meatal advancement glandular with release chordi (group M). The mean age of patients and duration of surgical wound healing in the two groups did not differ significantly. There was no significant difference between the two groups in terms of complications, including Bleeding, Hematoma, Meatus stricture, Wound infection, detachment of the wound edge, chordi after surgery, Balanitis and Urethral stricture but the incidence of fistula in patients undergoing Snodgrass repair was significantly higher than the group modify meatal advancement glandular with release chordi (P<0.05).

The method of modify meatal advancement glandular with release chordi compared to Snodgrass method is associated with fewer complications due to surgery, although further studies are recommended.

Macromastia in adolescent girls is a distressing condition. There is an increase in the number of patients opting for reduction mammoplasty in the late teens. The semicircular horizontal method of breast reduction, first described by Passot in 1925 has the advantage of being able to do larger reduction, particularly suitable for pendulous breasts and having a hidden scar in the inframammary fold.

Eleven patients of adolescent macromastia were included in this study. It was conducted over a period of 4 years (2013-17) at two teaching institutions in Kolkata and Rishikesh, India. The mean age of the patients was 19.2 years. The Passot technique of reduction mammoplasty was performed in each case and the volume of resected breast tissue recorded by weighing the specimen. The aesthetic outcome was assessed by Lowery scale (volume, contour, placement of the breast mound and inframammary fold). Patient satisfaction was assessed after 6 months of follow up on a scale of 1 to 10,  where 1-4 was poor, 5-6 fair, 7-8 good and 9-10 excellent.

Mean total reduction per breast was 856 gm. Patients reported a mean decrease of cup size by 1.5. The aesthetic outcome was excellent in 6 patients and good in 5 patients. Patient satisfaction was excellent in 9 patients and good in 2 patients.

Passot technique is a safe and effective technique of reduction mammoplasty and is especially useful in adolescent macromastia where the absence of visible scar on the breasts is very satisfying for the patients.

Macromastia in adolescent girls is a distressing condition. There is an increase in the number of patients opting for reduction mammoplasty in the late teens. The semicircular horizontal method of breast reduction, first described by Passot in 1925 has the advantage of being able to do larger reduction, particularly suitable for pendulous breasts and having a hidden scar in the inframammary fold.

Eleven patients of adolescent macromastia were included in this study. It was conducted over a period of 4 years (2013-17) at two teaching institutions in Kolkata and Rishikesh, India. The mean age of the patients was 19.2 years. The Passot technique of reduction mammoplasty was performed in each case and the volume of resected breast tissue recorded by weighing the specimen. The aesthetic outcome was assessed by Lowery scale (volume, contour, placement of the breast mound and inframammary fold). Patient satisfaction was assessed after 6 months of follow up on a scale of 1 to 10,  where 1-4 was poor, 5-6 fair, 7-8 good and 9-10 excellent.

Mean total reduction per breast was 856 gm. Patients reported a mean decrease of cup size by 1.5. The aesthetic outcome was excellent in 6 patients and good in 5 patients. Patient satisfaction was excellent in 9 patients and good in 2 patients.

Passot technique is a safe and effective technique of reduction mammoplasty and is especially useful in adolescent macromastia where the absence of visible scar on the breasts is very satisfying for the patients.

Surgical management of hair loss has become an increasingly challenging procedure, when dealing with scar alopecia. We investigated the efficacy of hair transplantation in patients with head and neck scar alopecia.

From 2016 to 2018 in Shiraz, Iran, all patients with scar alopecia in head and neck were evaluated for efficacy of follicular unit extraction (FUE), follicular unit transplantation (FUT) or a combination of two methods from donor sites in scalp and beard various hair-grafts were compared.

Fifty-six patients were enrolled. Most of them were between 31 and 40 yr old (48.3%) and male (71.4%). Trauma, burn, surgical excision of adjacent skin, radiotherapy and leishmaniasis were the registered causes. Scars were visible in scalp (39.3%), beard (28.6%), eyebrow (21.4%), and moustache (10.7%) regions. FUE (87.5%), FUT (10.7%) and a combination (1.8%) were the used methods. One-hair-grafts were used in eyebrows (100%), moustache (100%), beard (88%) and scalp (7.9%), while 2-hair-grafts in beard (6%) and scalp (47.4%) and 3-haired grafts in beard (6%) and scalp (44.7%) transplantations.

In head and neck scar alopecia, hair transplantation was selected based on type and depth of scar. FUE was targeted when huge grafts were not needed, including beard, moustache, and eyebrow, while FIT was used when extensive scars were present in scalp. One-hair-grafts were mostly applied for eyebrow, moustache and beard, 2-hair- and 3-hair- grafts for beard and scalp transplantation. These findings can be added to the literature when FUE, FIT, or their combination are targeted in hair restoration of scar alopecia in head and neck.

In many countries, there is no registry system to record data for Epidermolysis Bullosa patients. However, the first steps for establishing a registry system have been taken in Iran. Therefore, we decided to publish it for the first time.

This was a prospective cross-sectional study. Data was obtained from 538 patients consecutively enrolled in the Iranian Epidermolysis Bullosa Registry, using a detailed instrument created by burn research center of Iran University of Medical Sciences, Tehran, Iran from Jan 2017 to Sep 2017. Patients’ information such as age, gender, address, educational status, parents’ family relationship and pathology result were recorded. Then a physician examined patients focusing on gastrointestinal system, teeth, ophthalmologic disorders, psychological problems and contracture of the upper and lower limbs and any other complaint. Data entered SPSS ver.19 and analyzed using ANOVA and LSD tests.

Overall, 538 EB patients were registered in Iran (6.72 patient in 100.000 person) with an approximately equal ratio between males and females. Among 103 patients whose disease type was determined by a pathologist, 78 patients (75.7%) had dystrophic type, 13 (12.6%) junctional, 9 (8.7%) simplex and 3 (2.9%) kindler type. The most common complaint of patients was dysphagia followed by tooth damage.

We stablished a data registry for EB patients for the first time in Iran. The frequency of EB in Iran is less than many other countries. However, data completion is to be done to include all patients as possible.

The standard surgical treatment for low rectal cancer is abdominoperineal resection (APR). Comparing to primary closure, immediate flap reconstruction has shown to have good outcomes. We aimed to assess the inferior rectus abdominis muscle flap complications after APR surgery, a new method of reconstruction.

This study was conducted from 2014 to 2016 in a single center in Firoozgar Hospital, Tehran, Iran. Eighteen patients who underwent pelvic floor closure with inferior part of abdominis rectus musculofascial flap were included enrolled. The sampling method used in this study was census. All patients had distal rectoanal malignancies. A checklist including age, gender, tumor location, complications after surgery, tumor type, length of hospital stay, length of operation, neoadjuvant chemotherapy and neoadjuvant radiotherapy history was filled for all patients.

Among 18 participants, 27.8% were female. The mean age of participants was 58.28 ± 17.86 yr (minimum of 19 and the maximum of 89 yr). The pathology of the tumor in all but one of the cases was adenocarcinoma (94.4%). The overall complication rate after surgery was 27.8%. In total, 80% received neoadjuvant chemoradiotherapy. In a one year follow-up, 16.8% of patients died.

Inferior part of rectus abdominis muscle flap was a reliable and comparable means of reconstruction after APR surgery with low rate of complications and mortality.

Dislocation of mandibular condyle into the middle cranial fossa is rare but diagnosis and treatment timely is very important due to significant complications. In this paper, we present a very rare case of asymptomatic intrusion of the mandibular condyle into the middle cranial fossa after orthognathic surgery in a 23 year old man from Iran.

Minimally invasive surgeries are widespread and technically enhancing. Thyroidectomy is a common surgery and non-invasive adjustments make it more interesting. Neighbor neurovascular bundles need to be protected during minimally invasive thyroidectomy. A 15 yr old female who underwent minimally invasive thyroidectomy due to nodule, had presented with upper brachial plexus injury, without proper recovery despite physiotherapy cessions. She was operated in 2 stage reconstructive surgeries. First, musculocutaneous nerve innervated by 2 branches of median and ulnar nerves. Then, in a compound operation, axillary nerve innervated by long head branch of triceps nerve and suprascapular nerve by accessory nerve. She gained good function of upper limb. Minimally invasive operations in head and neck area can be disastrous, if surgeons do not consider anatomical points. Brachial plexus reconstructive surgeries are complicated operations to preserve hand functions following iatrogenic injuries.

Pyogenic granuloma following burns (PGB) manifest in patients with different clinical and pathological features which is completely different with classic pyogenic granuloma. Up to now, there is no conclusive theory about presents of PG and its accurate etiology. This is a short brief about a 49-yr-old female with, TBSA 1% which PG develop on her burned area after 2 weeks.

The reconstruction of the scalp following avulsion injury has always been a great challenge for plastic surgeons. Here we report a 25 yr old female presented with necrosis of left temporoparietal scalp skin over left temporo-parietal region following history of avulsion injury of the scalp four days back at all India Institute of Medical Sciences, Bhopal, India in 2018. After removal of the necrosed skin, the defect was successfully covered with Bipedicle fronto-occipital flap.

Fibrous dysplasia is a rare bony disorder with recurrent character distinguished by abnormal fibro-osseous tissue. One or more bones may be involved in this lesion; however, the maxilla is the most commonly affected bone in the maxillofacial region. Here, we present an interesting case of a surgically treated 12-year-old adult female patient with a diagnosis of craniofacial fibrous dysplasia (CFD) in the maxillary bone with an invasive expansion to the orbital bone who was referred to the Department of Oral and Maxillofacial, Mashhad Dental School, Mashhad, Iran, in Apr 2021. The patient was treated under general anesthesia by the surgical recontouring and bone shaving of the tumor. Several factors should be considered in choosing the best treatment such as pathological features of the lesion, patient’s age, and risk of recurrence. However, surgical treatment, in this case, was beneficial to help the patient resuming a normal life. There is no published report describing bone recontouring and shaving management in an invasive case of craniomaxillofacial FD before the age of skeletal maturity due to the psychological effect of the deformity.

Angiolipoma is an uncommon benign fatty tumor which is a variant of lipoma. Microscopic studies on angiolipoma show that it includes the mature lipocytes and blood vessels. Infiltrating angiolipoma is an un-capsulated angiolipoma and, due to penetration into the surrounding structures, complete excision of the tumor is difficult. According to previous studies, the relapse rate of the infiltrating angiolipoma after surgical intervention is 35-50%. Infiltrating angiolipoma is rarely seen in the head and neck region and often occurs in the trunk and limbs. In this study, we report a 10-year-old boy with periauricular infiltrating angiolipoma who underwent surgery. After surgery, the patient developed transient left frontal branch palsy, but recovery was excellent and after one year there is no relapse.