Marco F. Ellis

A geometric analysis of mastectomy incisions: Optimizing intraoperative breast volume.

INTRODUCTION The advent of acellular dermis-based tissue expander breast reconstruction has placed an increased emphasis on optimizing intraoperative volume. Because skin preservation is a critical determinant of intraoperative volume expansion, a mathematical model was developed to capture the influence of incision dimension on subsequent tissue expander volumes. METHODS A mathematical equation was developed to calculate breast volume via integration of a geometrically modelled breast cross-section. The equation calculates volume changes associated with excised skin during the mastectomy incision by reducing the arc length of the cross-section. The degree of volume loss is subsequently calculated based on excision dimensions ranging from 35 mm to 60 mm. RESULTS A quadratic relationship between breast volume and the vertical dimension of the mastectomy incision exists, such that incrementally larger incisions lead to a disproportionally greater amount of volume loss. The vertical dimension of the mastectomy incision – more so than the horizontal dimension – is of critical importance to maintain breast volume. Moreover, the predicted volume loss is more profound in smaller breasts and primarily occurs in areas that affect breast projection on ptosis. CONCLUSIONS The present study is the first to model the relationship between the vertical dimensions of the mastectomy incision and subsequent volume loss. These geometric principles will aid in optimizing intraoperative volume expansion during expander-based breast reconstruction.

Decreasing ALT donor site morbidity with the keystone flap

The anterolateral thigh (ALT) flap is a workhorse flap for a variety of wounds. The primary disadvantage of ALT flaps is donor site morbidity associated with large skin paddle defects. We present a strategy of managing the donor site with the Keystone flap to avoid skin grafts in cases where primary closure is not possible.

The Visor Flap: A Novel Design for Scalp Wound Closure

Abstract Full-thickness scalp defects pose a reconstructive problem in the setting of infection, radiation, and underlying calvarial defects. Current options include dermal matrices, skin grafts, and local fasciocutaneous flaps. Free tissue transfer is frequently required when scalp-based flaps fail or the wound is significantly large or complex. The authors present 7 patients of complex scalp defect reconstruction using the novel visor flap. The visor flap is a bipedicled advancement flap with a triangular posterior extension. The flap was designed to redistribute tension over a large surface area that prioritizes tension-free closure of the wound over a relatively small remote donor site. This method achieved complete primary healing of the recipient site in all patients. This flap design is a durable adjunct to minimize donor site morbidity and avoid microsurgical reconstruction of hostile scalp wounds.

Abstract: Patient-Specific Implants for Cranioplasty

1. Koltz PF, Myers RP, Shaw RB, et al. Reduction mammoplasty in the adolescent female: the URMC experience. International Journal of Surgery. 99 (2011): 229–232. 2. Iwuagwu OC, Walker LG, Stanley PW, et al. Randomized clinical trial examining psychosocial and quality of life benefits of bilateral breast reduction surgery. British Journal of Surgery. 2006. 93(3):291–294. 3. Singh KA, Pinell XA, and Losken A. Is Reduction Mammaplasty a Stimulus for Weight Loss and Improved Quality of Life? Annals of Plastic Surgery. May 2010; 64(5):585–587.

The Role of the Visor Flap in Scalp Reconstruction: A Case Series of 21 Patients

BACKGROUND Full-thickness scalp defects pose a reconstructive problem, especially in the setting of infection, chemotherapy/radiation, and underlying cranial defects. Current options include dermal matrices, skin grafts, and local flaps. Local flaps often fail, requiring subsequent microvascular free flap reconstruction. OBJECTIVE To describe the visor flap, a novel bipedicled advancement flap design, and its role in reconstruction of scalp defects. METHODS A retrospective review of 21 adult patients who developed scalp defects reconstructed using the visor flap from 2013 to 2017. The visor flap is a large bipedicled advancement flap design with a triangular extension at the base, which allows redistribution of a large surface area of the scalp. RESULTS All 21 patients achieved complete and viable soft tissue coverage of the recipient site, but 19.0% developed complications unrelated to flap viability, requiring reoperation (infected bone flap, epidural hematoma, and recurrent glioblastoma with subdural abscess). Only 1 patient required conversion to free flap reconstruction due to cerebrospinal fluid leak. Etiologies included cancer (76.1%), cerebrovascular disease (19.0%), and traumatic brain injury (4.8%). Preoperative radiation (42.9%), bone/hardware exposure (57.1%), and previous craniotomy (85.7%) were widely prevalent. Defect size ranged from 3 to 50 cm2 (mean, 16.9 cm2), and flap size ranged from 90 to 500 cm2 (mean, 222 cm2). CONCLUSION The visor flap provides an innovative solution for closure of scalp defects. This technique optimizes immediate closure of tissue compromised by infection or chemotherapy/radiation without burning bridges to more complex reconstructive options.

Conical Modification of Forearm Free Flaps for Single-Stage Reconstruction After Total Orbital Exenteration

Background: Orbital exenteration is a significant reconstructive challenge for plastic surgeons. Options described for these defects range from healing by secondary intention to free tissue transfer. The authors present our preferred reconstruction of orbital defects with free forearm-based flaps, which provides quality soft tissue and orbital contouring in 1 stage to consistently allow placement of bone-anchored implants for eventual orbital prosthesis. Methods: This conical shape of the orbit is deconstructed into a “Pac-Man” type shaped flap that leaves adequate depth for a prosthesis. A retrospective chart review was performed of 2 separate patients receiving orbital exenteration reconstruction by the senior author (MFE). Results: Two patients presented with adenoid cystic carcinoma of the orbit. Both patients underwent nonlid sparing orbital exenteration with adjuvant chemotherapy and radiation. Each patient subsequently developed delayed wound healing after prior local flap reconstruction. Vascularized radial forearm flaps in a Pac-Man shape were used in both patients. Both patients were discharged from the hospital on postoperative day 3. No partial or total flap loss was encountered. To date, each patient has undergone planning for osseointegrated implants. Conclusion: The authors present a simplified method of orbital reconstruction that provides high-quality vascularized tissue for resurfacing in 1 stage. This type of open-cavity flap reconstruction avoids the need for flap debulking procedures and facilitates 2-stage placement of osseointegrated implants.