Keuk Shun Shin

A New Arterial Flap from the Postauricular Surface: Its Anatomic Basis and Clinical Application

We studied the arterial pattern of the postauricular surface in 16 cadavers and compared them to the results of Doppler probing in the auricles of 15 human volunteers. The dissections revealed that the postauricular surface is mainly supplied by three to five sizable branches from the upper, middle, and lower divisions of the posterior auricular artery, traversing in a rather straight and cephalic direction toward the auricular rim. One or more branches of the middle division are constantly present and distribute over the upper two-thirds of the postauricular surface. These anatomic findings were compatible with the results of the Doppler probing. We have done four auricular reconstructions with postauricular arterial flaps with excellent postoperative results. It is worthwhile to use the postauricular arterial flap in restoring the middle third of the auricle.

A single-stage two-flap method of total ear reconstruction.

A single-stage two-flap method of total ear reconstruction in congenital microtia is reported. This method was derived from the one-stage reconstruction described by Song and Song. Two flaps defined by vascular basis were elevated on the mastoid area: the superficial skin flap supplied mainly by subcutaneous pedicled arteriole perforators from the posterior auricular artery and the deeper axial-pattern fascial flap including the posterior auricular artery itself. The ear framework, exaggeratedly carved using autologous rib cartilage, could be inserted easily between the two flaps, simultaneously producing the auriculocephalic angle and the conchal wall. Intraoperative expansion of the skin flap and postoperative external ear molding also were performed to create aesthetically pleasing ears.

The fasciovascular pedicle for revascularization of other tissues

A fasciovascular pedicle based on the epigastric vessels was developed in a rat model to determine if it could be used as a “universal carrier” to revascularize a new composite flap. The effects of time course, carrier size, and flap ischemia on the revascularization process were studied. A 2.5 x 4-cm or 1 x 4-cm fascial patch pedicled on the vessels was transferred under bipedicled 2.5 x 4-, 6-, or 8-cm abdominal panniculocutaneous flaps. At different time intervals, the flap was raised as an island flap connected only by it vascular bundle and then sutured back in place. The skin perfusion by dermofluorometry and flap survival were both markedly increased on day 5 (p < 0.001). The wide carrier had a 93% survival area, whereas the narrow carrier had only 71%. The wide carrier induced relatively faster and better revascularization (p < 0.05). Moderate ischemia promoted revascularization (p < 0.01). An india ink injection study and histological examination provided visual evidence of revascularization. This fasciovascular pedicle is a promising model for prefabrication of complex new composite flaps and for studying the process of revascularization between the layers. Based on these findings and further investigations, a thin, prefabricated abdominal free flap was successfully transferred for facial resurfacing in humans.

An improved burying method for salvaging an amputated auricular cartilage.

An improved burying method for salvaging an amputated auricle is presented. We elevated a mastoid skin flap and a fascial flap simultaneously and inserted the denuded auricular cartilage between them. This procedure can maintain the auricular cartilage in a more natural form by eliminating undue skin tension and can give a favorable aesthetic result.

Columella lengthening in nasal tip plasty of orientals

To elevate the nasal tip in Orientals, two simple adjunctive procedures are presented. Either V-Y advancement or earlobe composite graft can be used after the open rhinoplasty incision on the columella-labial junction. Over the past 6 years, 62 Oriental patients with short columella were treated with one of the above procedures. The nasal tip projection as well as nasal tip appearance greatly improved. The scar in the columellar base posed no problems, and none of the patients complained about the scar. The procedures are particularly useful for cosmetic rhinoplasty in Orientals as well as in cleft lip nasal deformity.

Reduction mammaplasty by central pedicle flap with short submammary scar

Reduction mammaplasty was performed in 30 patients by combining the central pedicle flap method with the short submammary scar (3-S) technique to avoid the common drawbacks of currently popular dermoglandular procedures. Reduction was accomplished by using perforating vascular branches from the pectoralis major muscle and its fascia supplying the nipple and breast parenchyme instead of the subdermal plexus. The central vascular pedicle supplying the nipple-areola complex was preserved. Only the periphery of the breast parenchyme was resected circumferentially, with the exception of the inferolateral portion, so as not to injure the sensory nerve. The remaining breast parenchyme was preserved in an inverted cone shape. The nipple-areola complex was safely transposed with great freedom, and the amount of resection was accurately adjusted for symmetry. No cases of nipple-areola complex sensory change occurred postoperatively, and lactation is possible because of preservation of the lactiferous ducts. The length of postoperative scars was reduced by using the short submammary scar technique. We believe this combined method is ideal in patients requiring resections ranging from 200 to 600 g per breast with good skin elasticity and moderate degree of ptosis.

Total palmar resurfacing with scapular free flap in a 26-year contracted hand.

The scapular free flap offers a large-sized and well-vascularized coverage for variable defects. It is not regarded, however, as a favorite tool for palmar resurfacing because of its bulky and rigid nature. A 28-year-old man had sustained a contact dermal injury at the age of 2 years that resulted in a severely deformed hand. The total palmar defect was resurfaced by surgical intervention with a scapular free flap. After secondary procedures, the final result was promising. The present report focuses on the secondary procedures, which make a more functional and aesthetically pleasing hand after coverage with the scapular flap. Also, our result suggests that even finger joints contracted for 26 years can recover motion if they have not been directly damaged.

Nostril sill augmentation in secondary cleft lip.

In most cases, after successful correction of primary cleft lip deformity, some problems remain to be solved. One of them is nostril sill depression, which should not be overlooked in cleft lip repair. However, there have been few reports on the anatomy of the depressed nostril sill and methods for augmenting the sill depression. The anatomy of the depressed nostril sill, its relationship to surrounding tissue, and the gross features of nostril sill depression in cleft lip deformity were reviewed, and a method in which a scar flap and a suture-fixation technique are used was developed for augmenting the depression. The clinical results of this method in 16 patients are presented.

Functioning free latissimus dorsi muscle transplantation: anterogradely positioned usage in reconstruction of extensive forearm defect.

We present a patient with successful functional recovery of a severely injured upper extremity after a microneurovascular free latissimus dorsi muscle and combined composite skin were transplanted with an anterograde position. In our patient, the anterogradely positioned usage of the lastissimus muscle offered two major advantages; one advantage was the direct anastomosis of a more proximal healthy uninjured recipient nerve without interpositional nerve graft, and the other, one-stage coverage including the elbow wound with combined scapular skin flap. From our result, we deduce that a neurovascular free latissimus dorsi muscle transplantation with an anterograde position is selectively indicated in functional recovery of an extensively injured forearm.

Restoration of finger extension and forearm contour utilizing a neurovascular latissimus dorsi free flap.

The use of a free neurovascular latissimus dorsi flap for restoration of wrist and finger extension and forearm contour is described in a burn patient. Wound coverage is the prime need of the extensive tissue loss in the upper limb, and a muscle or musculocutaneous flap is necessary to cover the exposed bone and muscles for infection control. Furthermore, restoration of the limb function as well as aesthetic flap donor and recipient site contour are needed. The case presented is the extremely rare patient in whom restoration of finger extension was achieved after the nearly total loss of the extensor forearm muscles.