Maniram Ragbir

Z-plasty modification of ulnar-based fasciocutaneous flap for closure of the radial forearm flap donor defect.

The radial forearm flap is a commonly used method of intra-oral reconstruction, but problems with the donor site are not uncommon. In an attempt to avoid complications, Elliot et al described the use of an ulnar-based flap to obtain direct closure. Where it was not possible to close the proximal defect using V-Y closure, the use of a split skin graft was recommended. We describe a modification of their technique that can potentially obviate the need of a split skin graft when proximal closure is not possible.

Multiple familial pilomatrixomas in three generations: an unusual clinical picture.

Pilomatrixomas are benign cutaneous tumors derived from hair matrix cells of unclear etiology. Pilomatrixomas commonly demonstrate somatic mutations in CTNNB1, a gene coding β‐catenin, a protein involved with hair follicle development. Multiple familial pilomatrixomas rarely occur and are most often associated with autosomal dominant conditions such as myotonic dystrophy and familial adenomatous polyposis (FAP). Nine families with multiple familial pilomatrixomas and no demonstrable underlying association have been reported in the literature. We present a tenth family in which five members spanning three generations grew multiple pilomatrixomas in the absence of any previously reported associations. No evidence of myotonic dystrophy, FAP, or other known associations was found. Extreme tiredness, behavioral problems, and sensory disturbances were common features across three generations but bore no temporal relation to the pilomatrixomas. The existence of a germline mutation in CTNNB1 to explain these symptoms has yet to be shown. Pilomatrixomas are potentially cutaneous markers of significant underlying pathologies. Patients presenting with multiple or familial pilomatrixomas should be thoroughly assessed for other pathologies and offered genetic screening to ensure that important diagnoses are not overlooked.

Banking a fillet flap to aid in reconstruction following a hindquarter amputation

A hindquarter amputation and hemipelvectomy for recurrent malignancy presents a reconstructive challenge to the plastic surgeon. Tumour resection leaves a considerable defect, with exposure of bone, neurovascular structures, pelvic and abdominal organs. A free lower leg fillet flap is a recognised method of providing soft tissue coverage, but ischaemic time is often lengthy as described in the literature. We present a unique method of providing soft tissue coverage using a free lower leg fillet flap, and minimising ischaemic time by banking the flap on the ulnar artery during the hindquarter amputation and tumour resection.Level of Evidence: Level V, therapeutic study.

Merkel cell carcinoma of the head and neck: challenges in implementing best practice.

ObjectiveMerkel cell carcinoma (MCC) is a rare, aggressive skin tumor. Controversies regarding optimal management persist due to inadequate data and knowledge regarding tumor biology. Head and neck MCC increases both oncological and reconstructive challenges, compounded by predominantly elderly patients. We review our practice and outcomes, review evidence, and discuss the difficulties in delivering best practice management. MethodsAll patients with primary head and neck MCC, managed by a single multidisciplinary team between January 2001 and December 2010, were identified through retrospective analysis of a pathology coding database. A literature review was performed. ResultsTwenty patients, with a mean age of 83.5 years (40–99 years) and presenting with mean symptom duration of 5 months, had primary tumors involving the nose (n = 2), periorbital region (n = 5), cheek (n = 6), and the temple and scalp (n = 7). Mean tumor size was 2.1 cm (range, 0.5–7.5 cm). Reconstructive techniques were direct closure (n = 8), skin grafting (n = 7), local flaps (n = 4), and free anterolateral thigh flap (n = 1). Two (10%) patients presented with nodal disease. Eight (40%) patients re-presented with nodal recurrence at a mean of 7 months with 6 undergoing salvage neck dissections. Adjuvant radiotherapy was completed in 5 cases, and chemotherapy used for palliation in 1 case. Most of the patients declined radiotherapy due to adverse effects or frailty. ConclusionsOur series demonstrates the profound challenges in managing head and neck MCC, including tailoring definitive primary treatment and current consensus management to elderly patients. Regional nodal assessment and management remains crucial to achieving this goal.

A free anterolateral thigh flap for pharyngeal reconstruction following dynamic hip screw femur fixation

Dear Sir, The free anterolateral thigh flap (ALT) is a fasciocutaneous flap first described in 1984 by Song, Chen, and Song (1984) and is usually based on either the musculocutaneous or septocutaneous perforators of the descending branch of the lateral circumflex femoral artery. It was first described for use in head and neck reconstructive surgery by Koshima et al. (1993) and has grown in popularity due to its long pedicle length, ease of harvest, and large amount of skin available. It is also used as a tubed fasciocutaneous flap for complete pharyngeal reconstruction. Dynamic Hip Screw (DHS) procedures are a well-established open reduction and internal fixation method for the treatment of extracapsular neck of femur fractures. AO guidelines state that a lateral approach to the proximal femur should be performed and following incision of the fascia lata the vastus lateralis muscle can be either reflected anteriorly if bulky or split longitudinally if atrophic (Raaymakers, Schipper, Rogier, & Werken, 2010). If split, this can result in damage to the musculocutaenous perforating vessels needed for a fasciocutaneous ALT flap. We recently encountered a case of a 54-year-old man who had previously undergone bilateral DHS procedures following extracapsular neck of femur fractures a number of years back. He was diagnosed with a laryngeal squamous cell carcinoma (SCC) and had a laser resection procedure followed by a functional laryngectomy for severe dysphagia. The pharynx was reconstructed with an anterior patch using a fasciocutaneous medial sural artery perforator free flap. An ALT flap was avoided due to previous DHS procedures and scarring on the lateral thigh. The procedure was successful but unfortunately histology of the resected larynx revealed recurrent SCC deposits with incomplete margins. It was decided to attempt a salvage procedure with redo total pharyngectomy and bilateral neck dissections. Total pharyngeal reconstruction with anterior neck skin replacement was indicated. Our flap of choice in this situation would be a chimerised tubed fasciocutaneous ALT free flap. We sought advice as to whether an ALT would be possible following DHS femur fixation and found that there was little published literature. Thankfully we were able to confirm that the orthopedic surgeon who performed the DHS reflected the vastus laterallis muscle rather than split it. This combined with good pre-operative handheld Doppler signals for perforators from the descending branch of the lateral circumflex femoral artery reassured us and we chose to proceed. (Figure 1). Intraoperatively, the flap was found to be pristine with virgin perforators and was raised and chimerised on these perforators before

Transoral robotic surgery for residual and recurrent oropharyngeal cancers: Exploratory study of surgical innovation using the IDEAL framework for early‐phase surgical studies

The purpose of this study was to identify the role of transoral robotic surgery (TORS) in the management of residual and recurrent oropharyngeal cancer.

Thumb reconstruction using a free osseocutaneous fibular flap following excision of an epithelioid haemangioendothelioma

Epithelioid haemangioendothelioma are a rare type of aggressive vascular tumour, which can occur in multiple areas of the body. Current treatment is surgical with wide excision of the tumour and surrounding tissue often resultant in large defects requiring reconstruction. We present the case of a patient with an epithelioid haemangioendothelioma affecting the proximal and distal phalanx of their dominant thumb. Local reconstructive options were poor given the wide excision margin including both skin and bone. After careful consideration, the decision was made to reconstruct the area using a free osseocutaneous fibula flap to provide both vascularised bone and an overlying skin paddle. We report the first documented case of a thumb reconstruction with an osseocutaneous free fibula flap following excision of an epithelioid haemangioendothelioma.Level of Evidence: Level V, therapeutic study.