Michael Scheflan

Breast reconstruction with a transverse abdominal island flap.

: A rectus abdominis musculocutaneous island flap for breast reconstruction following mastectomy is presented. The vascular anatomy of the abdominal wall has been clinically studied in patients undergoing abdominal lipectomy. Cadaver dissections are shown, demonstrating the anatomy, arc of rotation, and design alternatives of the rectus abdominis flap. The surgical technique is demonstrated and representative patients are shown.

The transverse abdominal island flap: part I. Indications, contraindications, results, and complications.

The transverse abdominal island flap is not just another myocutaneous flap. Although it derives its blood supply from myocutaneous perforators, the portion of the skin and fat that overlies muscle comprises only about 20% of its surface. The surface area of the flap by far exceeds the surface area of the entire muscle that carries it. Its hemodynamics are more complicated than usual and consist of delicate communications between the superior and inferior deep epigastric systems and the deep and superficial epigastric systems across the midline. Its use in breast reconstruction has been as exciting as it is complex. We describe our experience with 60 consecutive patients and 65 transverse abdominal island flaps.

Clinical trials of amniotic membranes in burn wound care.

Four test conditions of increasing complexity were used to evaluate the clinical efficacy of amniotic membranes as biologic dressings on donor sites and burn wounds in children. These were the clean-skin donor-site wound, the uncontaminated shallow partial-thickness burn wound, the bed of freshly excised full-thickness wounds, and the granulating surface of colonized burn wounds. The rate of epithelialization under amniotic membranes was the same as that under 5% scarlet red ointment or 0.5% silver nitrate solution dressings. Preservation of a healthy excised wound bed and maintenance of a low bacterial count in contaminated wounds paralleled the experience with human allograft dressings despite technical difficulties and the absence of vascularization of amniotic membrane and its fragile structure. Tentative conclusions are drawn as to the mechanisms by which biologic dressings exert their beneficial effects.

The Transverse Abdominal Island Flap: Part Ii. Surgical Technique

The purpose of this article—an adjunct to Part I appearing in January—is to describe in detail the surgical technique of the transverse abdominal island flap for reconstructing the female breast after mastectomy. This perioperative and intraoperative management scenario represents the consensus of both authors and is not intended as a rigid set of rules on “how to do it.” Rather it is hoped that these observations, based on our experience, will stimulate further expansion and refinement and more exact definition of the art and science involved in this concept. This portion of the article should not be considered independent of the perspective presentedin Part I regarding patient selection, indications, contraindications, and limitations of the transverse abdominal island flap.

Meningomyelocele closure with distally based latissimus dorsi flap

Our experience with the distally based latissimus dorsi flap in 12 patients (7 primary closures and 5 secondary procedures) indicates that it is an extremely reliable and useful flap in this setting. It provides coverage of the dural repair with viable soft tissues under a minimum of tension. The suture lines are distant from the dural closure, the donor defect closes primarily, and in the event of a complete failure, the contralateral latissimus dorsi remains available. In those cases of meningomyelocele where direct primary closure is not possible, we view this as the procedure of choice.

Ultrasonically assisted lipectomy in aesthetic breast surgery.

A case report of a young patient with marked asymmetry treated successfully with ultrasonically assisted lipectomy with a good functional cosmetic result, undetectable scars, and mammographic control and showing no ill-effect on the breast parenchyma is presented. Further studies and follow-up are needed to confirm the value and advisability of using ultrasonic energy in the female breast.

Combined erbium:YAG laser resurfacing and face lifting.

Facial aging occurs secondary to gravity-induced tissue ptosis and photoaging. Combined face lifting and carbon dioxide laser resurfacing provides a comprehensive one-stage approach to facial rejuvenation but is condemned by many plastic surgeons due to the nonspecific thermal effects of the laser and risk of skin necrosis. Newer high-energy erbium:YAG lasers allow precise tissue ablation with minimal thermal effect. In this study, various facial rejuvenation techniques were combined with simultaneous erbium:YAG laser resurfacing to assess results and complications. A total of 257 patients from Florida, Melbourne, Australia, and Tel Aviv, Israel, underwent combined erbium:YAG laser resurfacing and surgical facial rejuvenation. Various face-lift methods were used, including endoscopic, deep plane, and subcutaneous. Simultaneous, full-facial laser resurfacing was performed using a variety of erbium:YAG lasers. It was found that combined laser resurfacing and face lifting was successful in greater than 95 percent of patients with minimal morbidity. Two patients (1 percent) (both heavy smokers) developed small areas of skin necrosis that healed with minor pigment changes. Five patients (2 percent) developed synechia that was treated with no residual effect. Two additional patients (1 percent) developed temporary ectropion. There were no other cases of scarring, infection, or cosmetically obvious hypopigmentation. Although larger studies are necessary, it seems that the lack of thermal injury from the erbium:YAG laser makes it possible to safely perform laser resurfacing with surgical facial rejuvenation in nonsmokers. However, the authors caution that familiarity with the nuances of erbium:YAG laser resurfacing be obtained before performing combined laser resurfacing and face lifting.

Bilateral cleft lip repair: "putting it all together".

The surgical repair of the bilateral cleft lip should take into consideration restoration of normal anatomy throughout the lip. If it is well done, it contributes to both form and function. A composite technique is presented here, with additions taking advantage of all tissues and based on this principle. Preoperative orthodontic preparation is used to achieve more satisfactory spatial relationships when appropriate and to permit a one-stage repair without lip adhesions. The technical aspects are clearly outlined and supported by case presentations. The technique saves all tissue; avoids tightness; provides good muscular function; constructs a labial sulcus providing for proper movement of the lip; provides good nasal sills and floors; is adaptable to complete or incomplete clefts; can be easily revised or used for secondary revisions in other cases, and so on.

Surgical management of heel ulcers--a comprehensive approach.

Reconstruction of the ankle, heel, and foot remains a challenging, often frustrating problem for surgeon and patient alike. Little local soft tissue is available for the reconstruction, and often the underlying disorder precludes use of some procedures. The ankle and the heel are vital musculoskeletal structures, responsible for shock absorption, weight-bearing, and locomotion, and their dysfunction inflicts discomfort and disability on the individual that commonly lasts many months or even over a year. Soft tissue defects on the weight-bearing versus the nonweight-bearing surfaces present two quite different problems. Many surgical modalities, beginning with a skin graft and ending with microvascular transplantation of sensile tissues, are now available to the reconstructive surgeon for resurfacing the sole of the foot. We present a classification of heel ulcers based on their etiology, location, size, and the status of the peripheral circulation; offer new operative modalities and update the operations already available; and suggest an orderly approach to selecting an operation for reconstructing the foot.

The tensor fascia lata: variations on a theme.

Using more of the true musculocutaneous (or proximal) portion of the tensor fascia lata enables the surgeon to augment its bulk, include bone in the flap, close the donor site primarily, and use the flap even if the distal fascial compartment has been damaged. Alternative designs, inclusion of bone in the flap, and tetracycline bone labeling are discussed.