Jed H. Horowitz

Galeal-pericranial flaps in head and neck reconstruction anatomy and application

Head and neck deformities of congenital, traumatic, or neoplastic cause often require reconstruction. At the University of Virginia over the past 14 years, we have used galeal, temporalis fascial, and pericranial flaps to correct these defects in more than 150 patients. Dissection of these flaps on both cadavers and reconstructive patients had demonstrated new anatomic findings different from those reported in standard textbooks. The galea is the most superficial layer of fascia. The pericranium is the next tissue layer. It is continuous above and separate from the temporalis muscle fascia. We may, therefore, consider three separate fascial layers for reconstruction. A rich vascular plexus arises from branches of the external and internal carotid arteries. Blood flow is axial to the galea and temporalis fascia. Pericranium has a dual supply from peripheral axial vessels and from perforating vessels from the overlying galea. Galeal, temporalis fascial, and pericranial flaps are reliable, thin, and supple and have a good arc of rotation and minimal donor site morbidity. They may be used to cover bone, cartilage, or implants, may be folded for bulk, may be used to carry blood to poorly vascularized recipient sites, or may be used to nourish bone, cartilage, skin, and mucosal grafts. Their versatility permits a wide variety of potential applications in head and neck surgery.

Lawnmower injuries in children: lower extremity reconstruction.

Power lawnmower accidents are one of the most frequent causes of mutilating injuries in pediatric patients. Guidelines for the optimal surgical management of children differ from adult patients by several key anatomic, physiologic, and rehabilitative features. Small blood vessels in children less than 2 years old may prohibit microvascular surgery. Older children with larger vessels are often better candidates for microvascular flaps than their adult counterparts. Pediatric patients also resist recurrent ulceration of foot skin grafts, tolerate prolonged immobilization, and are rehabilitated more readily than adults. In considering these facts, we outlined an algorithm for surgical reconstruction. Split-thickness skin grafts are generally the first choice for coverage. The medial gastrocnemius is the workhorse of the knee and upper third leg. The soleus provides coverage for the middle third leg; microvascular flaps are used for large lower third leg defects. Crossleg fasciocutaneous flaps are good alternatives when microsurgery is not feasible. When possible, the weight-bearing surface of the foot should be covered with local vascularized sensate flaps; larger defects may require free flaps, crossleg, or gluteal-thigh flaps. Excellent functional rehabilitation has been achieved in our young patients through the combined efforts of the trauma service, plastic and orthopedic surgery, and physical and occupational therapy services.

External Cranioplasty: Historical Perspectives

Selective external cranial vault remodeling has been practiced since antiquity. The variations, methods, and desired results of external cranioplasty are as pervasive as the practice is old.

The bladder flap for urethral reconstruction in total phalloplasty.

At the University of Virginia Hospital we have developed a new technique of urethroplasty utilizing a full-thickness flap of bladder wall. Tubing and transfer of the flap may be completed in two stages. The bladder flap is approximately 28 X 4 cm in size. Strictures have not occurred with this technique, but special care is needed in placing the tube to avoid kinking of the new urethra at the angle where the penile urethra passes anterior to the pubic bone. In conjunction with modern methods of phalloplasty, a two-stage reconstruction of the entire phallus, including a functioning urethra, can be performed by combining the bladder wall flap with a modern (axial vessel) abdominal or groin skin flap. This will allow a patient to have satisfactory intercourse and permit orthostatic micturition with a minimum number of operative procedures.

Dermabrasion of Traumatic Tattoos: Simple, Inexpensive, Effective

In this article we describe the use of an electrosurgical cautery tip scratch pad for the treatment of traumatic (adventitious) tattoos. This inexpensive item is available in most surgical operating rooms. The pad is flexible yet firm and obviates the need for power equipment. Most important, the technique is simple, easy to learn, and highly effective.

Excision of multiple epidermal facial cysts in Gardner's syndrome.

A rhytidectomy incision is recommended to excise multiple facial epidermal cysts in patients with Gardners syndrome. The advantage of this approach is that it permits excision of excess skin over the cyst with esthetically pleasing hidden scars. The alternative to this procedure, a separate incision over each cyst, results in disfiguring and conspicuous scars.

A simplified method for air drill irrigation.

A modified No. 20 Foley catheter provides a simple, inexpensive method for intraoperative air drill burr irrigation.