Katsunori Yokoi

Functional reconstruction using a depressor anguli oris musculocutaneous flap for large lower lip defects, especially for elderly patients.

Described here is a new technique to reconstruct large lower lip defects using one or two musculocutaneous island flaps, which includes an innervated depressor anguli oris muscle and has a facial artery in its pedicle. Vermilion is simultaneously reconstructed using a mucosal transposition flap. Three patients who had a total lower lip defect and five patients who had a defect larger than one-half of the lower lip were treated by our procedure. All the flaps survived completely without any signs of vascular stasis. In six patients, sphincter function and sensation appeared within 3 months after surgery. In one patient who needed a total lower lip reconstruction, the depressor anguli oris muscle was atrophic and the motor nerve could not be found. This patient could not regain motion. One other patient complained of a sialorrhea accompanied by sensory loss; however, his sensation improved within 6 months after surgery. All of the reconstructed lower lips were large enough to enable the patient to wear dentures and were of a cosmetically acceptable appearance 1 year after surgery.

nasal Reconstruction Based on Aesthetic Subunits in Orientals

&NA; Reconstruction based on the aesthetic subunit principle has yielded good aesthetic outcomes in patients with moderate to severe nasal defects caused by trauma or tumor resection. However, the topographic subunits previously proposed are often unsuitable for Orientals. Compared with the nose in white patients, the nose in Orientals is low, lacks nasal muscle, and has a flat glabella; the structural features of the underlying cartilage and bone are not distinctly reflected in outward appearance. The authors devised aesthetic subunits suitable for Orientals, and they used these units to reconstruct various parts of the nose. The major difference between these units and those presented previously is the lack of soft triangles and the addition of the glabella as an independent unit. The authors divided the nose into the following five topographic units: the glabella, the nasal dorsum, the nasal tip, and the two alae. The border of the nasal dorsum unit was extended to above the maxillonasal suture. The basic reconstruction techniques use a V‐Y advancement flap from the forehead to reconstruct the glabella, an island flap from the forehead to reconstruct the nasal dorsum and nasal tip, a nasolabial flap to reconstruct an ala, and a malar flap to reconstruct the cheek. A combination of flaps was used when the defect involved more than one unit. This concept was used for nasal reconstruction in 24 patients. In one patient undergoing reconstruction of the nasal dorsum and in one undergoing reconstruction of the nasal tip, the texture of the forearm flap did not match well, which resulted in a slightly unsatisfactory aesthetic outcome. In one patient in whom the glabella, nasal dorsum, and part of the cheek were reconstructed simultaneously, a web was formed at the medial ocular angle, and a secondary operation was subsequently performed using Z‐plasty. In one patient undergoing reconstruction with a forehead flap, defatting was required to reduce the bulk of the subcutaneous flap pedicle at the glabella. However, suture lines were placed in the most inconspicuous sites in all patients, and the use of a trapdoor contraction emphasized the three‐dimensional appearance of the nose. The use of these aesthetic subunits for reconstruction offers several advantages, particularly in Oriental patients. Because the nasal dorsum is reconstructed together with the side walls, tenting of the nasal dorsum is avoided, which prevents a flat appearance of the nose. A forehead flap is useful in the repair of complex defects. Defects of the alae should be separately reconstructed with a nasolabial flap to enhance the effect of the trapdoor contraction and to highlight the three‐dimensional appearance of the nose. Candidates for reconstruction should be selected on the basis of nasal structure. The results suggest that these units can also be used in some white patients. (Plast. Reconstr. Surg. 106: 36, 2000.)

Estlander flap combined with an extended upper lip flap technique for large defects of lower lip with oral commissure

Various methods of reconstructing lower lip partial defects have been reported, for example those using the upper lip such as the Abbe and Estlander flap techniques. However, when a large defect of the lower lip with oral commissure is presented, the choice of reconstruction method is often difficult. For such cases, the Estlander flap technique is often used, although displacement of the oral commissure is one of the remaining problems. In the case of large defects of the lower lip with oral commissure, we opted for a reconstruction method in which the entire upper lip was incised and extended, a portion of which was reflected as a traditional Estlander flap. Four cases were treated using this method, and in all cases there were no complications such as venous return disturbance, and the site healed well. Sensation returned within 3 months, and contraction of the lips appeared within 6 months. The symmetry of oral commissures was maintained and the appearance was almost cosmetically satisfactory. Our technique is especially useful for reconstructing defects affecting 1/3-2/3 of the lower lip including the oral commissure. This technique is cosmetically and functionally successful and the symmetry of the oral commissure is maintained.

Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle.

Herein is described a technique that uses a combination of local flaps to reconstruct large defects involving the nasal dorsum and cheek. The flaps used are a transposition flap elevated from the area adjoining the defect and bilateral cheek advancement flaps. This technique leaves all suture wounds at borders of the aesthetic subunits that have been described previously. Color and texture matches were good and symmetrical. The transposition flap can be modified according to whether the defect includes the nasal tip. After raising the cheek advancement flap, it is also possible to use a dog‐ear on the nasolabial region for any alar defects. Nine patients were treated using this procedure. The technique is very reliable (no complications such as congestion and skin necrosis in our series) and is easy to perform. One patient had palpebral ectropion after the operation and underwent secondary repair. In this series, defects measuring 45 × 30 mm in maximum diameter and including the nasal dorsum, nasal tip, ala, and cheek were treated. (Plast. Reconstr. Surg. 107: 1358, 2001.)

Management of the hairline using a local flap in total reconstruction for microtia.

In cases of microtia with a low hairline, the manner in which hair is removed from the reconstructed auricle must be taken into consideration. This is one of the most common but difficult problems with reconstruction for microtia. The authors describe a new technique that uses a simple regional flap to resolve this problem. The hair-bearing skin in the estimated auricular region and its covering are removed using a local flap from the hairless mastoid region. This is done in the first stage of auricular reconstruction, the costal cartilage grafting is done in the second stage, and elevation of the auricle is done in the last stage. In 38 auricles of 36 patients who were treated from 1993 to 1995, eight auricles of eight patients were treated with this technique. In all cases, the hairless flap healed well, without vascular stasis or skin necrosis. In addition, no complications from using this technique occurred in the later stages of auricular reconstruction. With this technique, the skin of the flap provides a good texture and color match to the auricle. In addition, the skin of the flap has good elasticity for the cutaneous pocket for cartilage grafting. The harvested area of the flap can be hidden behind the reconstructed auricle. The authors initially wondered whether the marginal scar of the transposed flaps position in the auricle would be conspicuous. However, all of the scar became inconspicuous because it was positioned in the scaphoid fossa.

Reconstruction of congenital stenosis of external auditory canal with a postauricular chondrocutaneous flap

&NA; We describe here a new surgical technique for treatment of congenital stenosis of the external auditory canal using a postauricular chondrocutaneous flap. Our technique prevents recurring stenosis by cartilage support and provides a sufficient extension of the canal. The chondrocutaneous flap is safely elevated, easily reaches the canal, and has ample blood supply. It is beneficial for its self‐cleaning function that the remnant canal, which contains cerumen glands, is used as part of the reconstructed canal. Six patients with congenital stenosis of the external auditory canal were treated by our procedure. In these patients, three patients were treated by a postauricular approach and the others were treated by an endaural approach. All patients had very satisfactory results. (Plast. Reconstr. Surg. 102: 2320, 1998.)

Facial injury by mercury from a broken thermometer

The case of a 2-year-old girl with a facial soft-tissue injury from an accident with a mercury thermometer is presented. All tissues containing droplets of metallic mercury should be removed immediately and careful examination for signs of mercury poisoning should be conducted over the long term.

Nonsurgical treatment of various auricular deformities

Nonsurgical treatment does not always correct all auricular deformities. However, we believe that all types of deformities can be treated if the gradual and continuous correction is made. Therefore, it is recommended that nonsurgical treatment should be tried first, even in older children. Even if the correction with the splint is not satisfactory, the improved form with the splint will make it easier to obtain a good, delicate form by surgery at a later stage.

Modified thin abdominal wall flap (glove flap) for the treatment of acute burns to the hands and fingers

BACKGROUND Burns to the dorsum of the fingers and hands require debridement and immediate coverage by skin flap at the earliest opportunity. In such situations, the conventional abdominal wall flap is still commonly used as it is a convenient and safe technique, but the foremost problem with this flap is that it is thick and therefore cosmetically unacceptable; it is also functionally not very suitable as the bulkiness of the digits prevents full range of motion. We have developed a modified thin abdominal flap (glove flap) which attains good results. METHODS Incisions are made in the skin of the abdominal wall only where the hand is to be inserted and where each of the finger tips will be pulled through. The flap is undermined just under the skin to the depth that preserves the subcutaneous vascular networks to create a thin flap. The interdigital area of the flaps should not be undermined so as to create a glove-type pocket. The hand is then inserted in this subcutaneous pocket. After insertion of the injured hand for 10 to 14 days, the flap is resected and attached to the hand. RESULTS Seven hands of 5 patients were treated by this technique and all the flaps survived safely. The function of the hands and fingers, including range of motion (ROM) in each joint, was successfully salvaged. The reconstructed hands and fingers were aesthetically pleasing. CONCLUSIONS Although the abdominal wall flap is not a new technique, our modifications to this flap make it possible to acquire functionally and aesthetically better results. Although many excellent techniques such as perforator flaps have been reported recently, we conclude that the abdominal wall flap is still a very useful technique because it can be performed easily, safely and within a short time.

New way to raise the V-Y advancement flap for reconstruction of the lower lip: Bipedicled orbicularis oris musculocutaneous flap technique

Abstract We describe a new way to raise the V-Y advancement flap, which is useful for reconstruction of the lower lip. Various other methods have been reported in the past, but it has been necessary to choose the most suitable method for each particular case. A V-Y advancement flap from the submandibular region is one of the useful techniques to reconstruct the lower lip, and it is suitable for a wide horizontal defect. However, the conventional V-Y flap is insufficiently mobile and the reconstructed vermilion is thin because of the limitation of the pedicle. In such a case, the reconstructed lip may sag or cause an embarrassing defect. We developed a new way to raise the flap to obviate these problems. We use the V-Y advancement flap from the inferior margin of the defect in a conventional way after excision of the tumour, and use a mucosal flap to reconstruct the vermilion border. The skin side of the V-Y flap is undermined, and the orbicularis oris muscles are preserved on both sides as pedicles. The flap is then raised as a bipedicled musculocutaneous flap, which has adequate movement. After the flap has been sutured, the superior margin of the flap is de-epithelialised, and used to create the volume of the vermilion border. Functionally and cosmetically good results were achieved.