Hans Holmström

The Free Abdominoplasty Flap and Its Use in Breast Reconstruction: An Experimental Study and Clinical Case Report

In search for a free microvascular flap which would give abundant reconstructive material as well as a satisfactory donor site the free abdominoplasty flap was developed. The flap is designed on the area between the umbilicus, the pubic region and the anterior superior iliac spines and is based on the inferior epigastric vessels on one side only. In eight regular abdominoplasty procedures elevation of this flap and keeping the blood flow intact through the isolated vessels did not jeoparding the viability of the flap. Angiography of the specimens showed a good perfusion. The free abdominoplasty flap has been used for breast reconstruction in 2 cases of radical mastectomy. The first was failure because of venous thrombosis. In the second case 3 veins were anastomosed, 2 venae comitantes to the inferior epigastric vein and the contralateral superficial epigastric vein and the result was favourable.

The lateral thoracodorsal flap in breast reconstruction.

A fasciocutaneous transposition flap, the lateral thoracodorsal flap, has been used in 114 cases of breast reconstruction. This flap is raised from the lateral and dorsal aspects of the thoracic wall at the level of the submammary crease, and the size may be varied from 12 to 22 cm in length and 6 to 12 cm in width. The lateral thoracodorsal flap is used with an implant and forms the lateral part of the reconstructed breast. A natural ptotic breast shape is achieved in a single-stage procedure. Complications such as partial necrosis and infection have occurred in 3.5 and 2.5 percent of cases, respectively. The procedure is simple and has at our unit largely replaced the use of the latissimus dorsi musculocutaneous flap in extensive postmastectomy defects. In less disfiguring defects, the lateral thoracodorsal flap has taken the place of direct implantation because the reconstructed breast obtains a more pleasing shape by augmentation of the lower lateral pole.

Surgical treatment of non-traumatic lower lip lesions with special reference to the step technique. A follow-up on 149 patients.

During a 10-year period 149 patients with non-traumatic lesions of the lower lip were operated with various methods. To overcome certain functional drawbacks with the procedures used in the early cases a new technique was developed and used in 102 cases. In order to preserve functional orbicular continuity and intact labial commissures, one or two advancement flaps from the remaining parts of the lower lip were moved in a stepwise fashion to bridge the defect. The step technique could be used for defects up to two-thirds of the lower lip, which constituted adequate resection in the vast majority of the lower lip cancers in the present series. The functional and cosmetic results of this method were satisfactory regarding sensibility, mobility, symmetry and width of the oral orifice. 69 cases of primary cancer of the lower lip had a 3 year cure rate of 100%. 27 cases treated for recurrent cancer after radiotherapy and/or earlier surgical treatment had an overall 3-year cure rate of 77%. The importance of ad...

Clinical and pathologic features of maxillonasal dysplasia (Binder's syndrome): significance of the prenasal fossa on etiology

Clinical and pathologic anatomic parameters were studied in 50 patients with maxillonasal dysplasia (Binders syndrome). The skeletal deformity causing the flat and low-set nose was in typical patients a palpable depression in the anterior nasal floor (fossa prenasalis) and a localized maxillary hypoplasia in the alar base region. Class III malocclusion was found in 54 percent. In 6 percent of the patients a slope (sulcus prenasalis) was found instead of a fossa in the anterior nasal floor, and in one patient a rudimentary fossa was found. Concomitant malformations were noted in 18 percent, and a hereditary connection was seen in 16 percent. The etiology is discussed in relation to the development of the premaxilla and the appearance of a secondary external trabecular network of bone in the canine region. An inhibition of the latter ossification center would explain the localized hypoplasia in the floor and walls of the piriform aperture in maxillonasal dysplasia.

Nipple Reconstruction with a Modified S-Flap Technique

A modified S-flap method for nipple reconstruction with two local opposing skin flaps, was used for a series of 21 women with a mean age of 50 years (range 30-64). Four patients had bilateral breast reconstructions, so the total number of reconstructed nipple areola complexes (NAC) was 25. The patients were examined 29-46 months (mean 36) after the reconstruction with particular reference paid to projection, size, sensation, and colour of the nipples. The patients also answered a questionnaire about their assessment of the final result. The mean projection of the nipples was 3.9 mm (range 0-9). Five patients had various degrees of necrosis of the skin flaps. One third of the women had some sensation in their reconstructed nipples. Two thirds of the nipples were pale. The patients estimated the final result as 8.2 (range 1-10) on a visual analogue scale.

Surgical correction of the nose and midface in maxillofacial dysplasia (Binder's syndrome)

In 48 patients with maxillonasal dysplasia the retruded nasal base was corrected with onlay cancellous bone grafts after subperiosteal dissection using an oral vestibular approach. Support for the nasal dorsum was achieved in 39 patients with an L-shaped bone graft from the iliac crest introduced through the same approach. The advancement of the nose was found stable on lateral cephalograms; i.e., resorption did not occur. However, the grafts showed considerable remodeling. Half the patients found the stiffness of the nose to be disturbing. In nine patients, the cartilaginous septum was used instead as a support for the nasal dorsum and tip. At operation, the entire cartilaginous septum was mobilized after subperichondrial dissection and rotated forward either pedicled at the nasal dorsum or completely released. Cartilage regenerated in the periochondrial pocket left behind the advanced septum. The anterior transfer of the nose was 6 to 10 mm. The use of septal advancement is preferred over bone implants in the correction of maxillonasal dysplasia in patients in whom the bony nasal dorsum is of adequate height because it results in a soft and flexible nose and the risk of traumatic fracture and resorption is eliminated. The technique has been used in adolescents with promising results.

Vaginal construction with skin grafts and vacuum-assisted closure.

Probably the most common method of constructing a vagina in patients with the Mayer-Rokitansky-Küster syndrome is the technique popularised by McIndoe and Banister in 1938. A cavity is created between the rectum and urethra-bladder complex and is lined with split-thickness skin grafts. One of the disadvantages of using split-thickness skin grafts is the incidence of late contraction of the neovagina. To avoid this problem full-thickness skin grafts have been used, but their take is less reliable. A new technique to improve the take of skin grafts is the VAC-system (vacuum assisted closure, KCI) which has proved to be particularly valuable in grafting difficult anatomical sites. We have used the VAC-system in the construction of a vagina in one case with split-thickness skin grafts and in two cases with full-thickness skin grafts. In all three cases the take was excellent with little discomfort for the patients. It was not necessary to stent the neovagina in the postoperative period and coitus was possible within a month of operation.

The Lateral Thoracodorsal Flap In Breast Reconstruction: A Long Term Follow Up Study

Fifty-four patients were studied a mean of five years after their breasts had been reconstructed between 1984 and 1990 using the lateral thoracodorsal (LTD) flap in combination with either a thin shell, non-low-bleed (n = 35) or a thick shell, low bleed (n = 19) silicone gel implant. The rate of capsular contracture (Baker III-IV) was 11% in the first group and 10% in the second according to a modified Baker classification. Open capsulotomy was common in both groups of patients (15/35 in the first group and 13/19 in the second). Investigation by applanation tonometry of the capsular contracture agreed with the modified Baker classification. The cosmetic results were evaluated clinically and from photographs. Best scores were recorded for scars and ptosis in both evaluations. There were no significant differences between the general cosmetic results in the two groups. The patients graded their estimations of the final outcome of their breast reconstruction on a 10-point visual analogue scale (VAS); the mean for the first group was 8.7 and for the second 9.2. None of the patients regretted her operation and they would all recommend the procedure to another patient.Fifty-four patients were studied a mean of five years after their breasts had been reconstructed between 1984 and 1990 using the lateral thoracodorsal (LTD) flap in combination with either a thin shell, non-low-bleed (n = 35) or a thick shell, low bleed (n = 19) silicone gel implant. The rate of capsular contracture (Baker III-IV) was 11% in the first group and 10% in the second according to a modified Baker classification. Open capsulotomy was common in both groups of patients (15/35 in the first group and 13/19 in the second). Investigation by applanation tonometry of the capsular contracture agreed with the modified Baker classification. The cosmetic results were evaluated clinically and from photographs. Best scores were recorded for scars and ptosis in both evaluations. There were no significant differences between the general cosmetic results in the two groups. The patients graded their estimations of the final outcome of their breast reconstruction on a 10-point visual analogue scale (VAS); the mean for the first group was 8.7 and for the second 9.2. None of the patients regretted her operation and they would all recommend the procedure to another patient.

HTR® polymer facial implants: A five-year clinical experience

Forty-three patients at two different international sites underwent onlay facial augmentation of the malar, paranasal, and chin regions using 61 HTR polymer preformed implants. All implants were placed intraorally and rigidly fixed with a titanium screw. Over postoperative periods ranging from two to five years, one implant was removed because of infection. Two other implants in patients with rheumatic and connective tissue disease were removed because of persistent pain and erythema. Another peri-implant infection was treated successfully without removal. Oneyear postoperative radiographs in patients with chin implants demonstrated no underlying bone resorption. This porous polymeric material appears to offer clinical results comparable to other alloplastic materials for onlay facial skeletal augmentation.

Surgical treatment of eyelid cancer with special reference to tarsoconjunctival flaps. A follow-up on 193 patients.

203 cancers of the eyelid were operated on in 193 patients. 65% of the tumours occurred in males and the peak incidence was at 75 years. 60% afflicted the lower eyelids and 21% the medial canthi. Basal cell carcinoma were found in 182 specimens and spinocellular carcinoma in only 8. Malignant melanoma, Meibomian gland carcinoma and rhabdomyosarcoma appeared each in one patient, the latter representing the only fatal case in eyelid cancer. All cancers were excised with a free margin around 5 mm. The standard procedures of reconstruction of the eyelid defect were a fullthickness skin graft in cases where conjunctiva and tarsus could be preserved (97 cases), and a tarsoconjunctival flap in full-thickness defects of the lower eyelid (58 cases). Other methods used were wedge excision and direct approximation in very small lesions involving the lid margin, an infratarsal island flap from the lower eyelid for medium-sized to large defects in the upper lid and a forehead or scalp flap after exenteration of the orbit. 18/203 cancers recurred and 12 of these were primarily regarded as radically treated. Seven of the latter were reoperated after more than 3 years and may in fact be new tumours. No metastases were found. The various reconstructive procedures are discussed in detail