Zoltán Lóderer

Surgical Management of Progressive Hemifacial Atrophy With De-Epithelialized Profunda Artery Perforator Flap: A Case Report

Progressive hemifacial atrophy (PHA) is a rare disorder characterized by slow, unilateral atrophy of the soft tissues and bones of the craniofacial region. The defect becomes more pronounced with age, leading to esthetic and functional deficits. However, the proper timing and method of surgical reconstruction are still debated. The correction of this defect markedly influencing the quality of life of the patient can be achieved with less invasive to more invasive surgical approaches. A 21-year-old female patient with hemifacial atrophy and extensive alopecia presented to our clinic. Considering the body type and the expectations of the patient, a profunda artery perforator flap was applied for the reconstruction and esthetic improvement of the facial region. The facial asymmetry attenuated after the reconvalescence period. This case shows that in the up-to-date surgical treatment of severe PHA, the use of microvascular free flaps may provide a better approach when trying to achieve an acceptable esthetic result. This is the first time that a profunda artery perforator flap was used to restore facial asymmetry caused by PHA.

An anterolateral thigh chimeric flap for dynamic facial and esthetic reconstruction after oncological surgery in the maxillofacial region: a case report

BackgroundThe surgical management of malignant tumors in the head and neck region often leads to functional and esthetic defects that impair the quality of life of the patients. Reconstruction can be solved with prostheses in these cases, but various types of microsurgical free flaps can provide a better clinical outcome.Case presentationIn this case report, the tumor and parts of the involved facial muscles and nerve were excised surgically from a 42-year-old patient after a third relapse of basal cell carcinoma in the left midface. The tissue defect was reconstructed with an anterolateral thigh chimeric type I fascio-myocutaneous flap, where the facial palsy was restored with a segmental branch of the femoral nerve and the involved mouth corner elevator muscles for the segmented vastus lateralis muscle. The 6-month follow-up revealed a good esthetic outcome, the soft tissue defect reconstruction with good functional activity of the reconstructed facial nerve and with acceptable mimic movements. There has been no subsequent recurrence.ConclusionsIt is concluded that the chimeric type I anterolateral fascio-myocutaneous free flap can offer a good option for the esthetic and functional reconstruction of an extensive tissue defect in the maxillofacial region.

Autologous Dermis Graft Implantation: A Novel Approach to Reinforcement in Giant Hiatal Hernias

Objectives Nonreinforced tensile repair of giant hiatal hernias is susceptible to recurrence, and the role of mesh graft implantation remains controversial. Creating a new and viable choice without the use of high-cost biological allografts is desirable. This study presents the application of dermis graft reinforcement, a cost-efficient, easily adaptable alternative, in graft reinforcement of giant hiatal hernia repairs. Methods A 62-year-old female patient with recurrent giant hiatal hernia (9 × 11 cm) and upside down stomach, immediately following the Belsey repair done in another department, was selected for the pilot procedure. The standard three-stitch nonabsorbable reconstruction of diaphragmatic crura was undertaken via laparoscopic approach. A 12 × 6 cm dermis autograft was harvested from the loose abdominal skin. “U” figure onlay reinforcement of diaphragm closure was secured with titanium staples. The procedure was completed with a standard Dor fundoplication. One- and seven-month follow-ups were conducted. Results No short-term postoperative complications were observed. One-month follow-up showed normal anatomical location of abdominal viscera on computed tomography imaging. High-resolution manometry showed normal lower esophageal sphincter pressure. Preoperative abdominal complaints were resolved. Procedural costs were lower than the average cost following mesh graft reinforcement. Conclusion Dermis graft reinforcement is a cheap, easily adaptable procedure in the repair of giant hiatal hernias, even in the setting of laparoscopic reoperative procedure.

Double Diep Flaps for Unilateral Breast Reconstruction

DIEP flap is the first and the most frequent choice to reconstruct a breast by using autologous tissue. The procedure may be challenging among patients who had a lower median laparotomy before and whose contralateral breast’s volume requests the transplantation of all the lower horizontal abdominal tissue (also two DIEP flaps) to get a good size matching. With five such patients, double DIEP flaps were transplanted microsurgically to reconstruct the previously removed breast. All the patients healed without any complications and with good aesthetic results. This technique provides a safe approach and broadens the armamentarium of breast reconstruction.

Plasztikai sebészet és fej-nyak sebészet együttműködése nem szokványos esetek ellátása kapcsán. Veszprém, 2010–2015

Absztrakt Bevezetes: A fej-nyak regioban felmerulő feladatok megoldasa gyakran tarsszakmak szoros egyuttműkodeset igenyli, ahogy az altalunk bemutatott kihivast jelentő esetekben is. Betegek es modszer: Az első betegnel bal arcfelen recidivalo basocellularis carcinoma miatt radikalis műtet, majd chimera I. tipusu anterolateralis thigh (ALT) lebennyel rekonstrukcio tortent. A masodik beteg eseteben jobb arcfelet erintő laphamcarcinoma miatt vegeztunk radikalis műtetet es chimera I. tipusu thoracodorsalis lebennyel rekonstrukciot. Harmadik betegunknel veleszuletett bal oldali hemifacialis microsomia miatt profunda arteria perforator (PAP) lebennyel tortent helyreallito műtet. A negyedik betegnel serulesből fakado jobb oldali hemimandibula-hiany miatt computer-aided design and computer-aided manufacturing (CAD-CAM) technikaval megtervezett rekonstrukciot vegeztunk szabadfibula-atultetessel. Eredmenyek: Valamennyi valasztott rekonstrukcios megoldas a problemak kezeleseben hatekony es biztonsagos lehetősegnek ...

Aesthetic outcome as a goal using pectoral muscle-strip in recurrent subareolar abscess of the breast and for double subdermal flap in modelling of the inverted nipple

Recurrent subareolar abscess (RSA) is an uncommon benign disorder of the non-lactating young and mid-aged female breast [1]. It was first described by Zuska et al. [2], in 1951, as a chronic inflammation of the sinuses of lactiferous ducts with a clinical spectrum that may manifest as nipple discharge or distortion, recurrent subareolar abscess or mamillary duct fistula [1–3]. Epithelial metaplasia of the lactiferous ductal system is considered as an important etiological factor [4]. Epithelial shreds and debris lead to ductal occlusion, thus to ductectasia and secondary infections and abscess formation. The definitive treatment of chronic peri-ductal mastitis requires radical excision of the abscess along with major ducts and the discharged, distorted central portion of the mammilla and has been described in detail by several authors [3, 5, 6]. Nevertheless, published series described recurrence rate of 9 % [3] and 28 % [5] following such procedures. In some rare cases, when peri-mammillary excisions failed, even mastectomy was performed [3] as a radical outcome. In 2009, Low and Barry [1] published a sally procedure with adaptation of a pectoral major muscle flap. We successfully adapted a modification of that procedure in cases of recurrent peri-ductal mastitis refractory to repeated radical surgeries, ductectomies and courses of steroid and antibiotic treatments: total major duct excision was performed from a peri-areolar incision with central posterior mamillectomy and partial excision of the distorted nipple-areolar complex. Inflammatory debris and necrotic tissue were thoroughly debrided prior to preparation for the ‘‘pectoral-strip’’ flap. The pectoral strip is formed as a flap of the lateral edge of the pectoral muscle with a vascular shaft. A tunnel wide enough to comfortably transmit the flap without undue tension causing vascular compromise was fashioned through the breast tissue, extending from the periareolar skin incision to the cephalad end of the muscle flap. The free edge of the mobilized flap is delivered via the tunnel to the sub-areolar space and sutured under the mamillary and surrounding tissues (Fig. 1). Three months later, the inverted mammilla was reconstructed in local anaesthesia. The nipple was averted with a traction suture and two triangular incisions were made. The flaps were deepithelialized and the pectoral muscle underlying the dermis was prepared creating two muscular-dermal flaps. A tunnel is prepared under the mammilla and the pectoral muscle-dermal flaps on both sides of the inverted nipple are advanced in opposite position beneath the nipple and stitched. A modelled ‘‘donut’’ dressing was applied and continuous traction of the nipple lasted 3 weeks to avoid compression of the nipple and to achieve persistent projection. Recurrent sub-areolar abscess (RSA) is an uncommon breast disease of which the pathogenesis is still largely unknown. Lannin [4] treated 67 cases during 22 years. In an analysis of 58 patients with RSA, Li et al. [3] performed 33 major ductectomies in addition to the central excision of the distorted nipple and reported a recurrence rate of 9 %; however, even two mastectomies were performed for this benign condition. RSA is strictly a benign disorder of the non-lactating young and mid-aged female breast. Smoking is supposed as an important risk factor [7], causing local microvascular ischaemia in the peri-areolar region preventing resolution of localised infection leading to recurrent G. Bognar (&) G. Ledniczky 2nd Surgical Department, Semmelweis University Budapest, Kútvölgyi út 4, 1125 Budapest, Hungary e-mail: bgabor68@gmail.com

Retroareolarisan elhelyezkedő emlőtumorok onkoplasztikai műtéte: centrális quadrantectomia és Grisotti-féle inferior dermoglandularis lebennyel való rekonstrukció

Centrally located breast cancers account for 5-20% of all breast cancer cases. Historically, patients with central breast cancers were not offered breast conservation surgery but conventional mastectomy only. The relatively frequent nipple-areola-complex involvement and consequent nipple-areolar resections with an adequate safety margin around the tumor usually result in an unacceptable cosmetic result. However, breast conservation surgery can be offered to these patients applyingoncoplastic surgical techniques. In this study, central quadrantectomy and breast reconstruction with Grisottis dermo-glandular flap is evaluated.

Többszörösen kiújult sacralis dermoid definitív megoldása az arteria glutealis inferior direct fasciocutan ágára nyelezett transzpozíciós lebeny alkalmazásával

AIM Treatment of sacral dermoid cysts (SDC) is a surgical challenge. Etiology and adequate operative technique of that are debated widely up to now, and recurrence rates remained high despite various surgical techniques applied. In cases of unsuccessfully operated and repeatedly recurrent SDC a fascio-cutaneous flap on the first perforating branch of the inferior gluteal artery (IGA) is a definitive procedure. MATERIAL AND METHOD Following preparation and dissection of sidebranches of IGA in cadavers, a repeatedly recurrent SDC was operated. CONCLUSION a flap harvested and transferred on the first superficial perforating branch(es) of the inferior gluteal artery offers a definitive and recurrence-free surgical solution for SDC.

Reconstruction of soft tissue defect of the sole using an ALT flap

Soft tissue defect of the sole is usually a quite challenging problem. In this case report the most frequently used reconstructive options of this problem are reviewed paying particular attention for the well applicable and reliable types. An ALT graft as a free flap to the sole offers a good possibility for coverage, which is resistant enough to mechanic strains.

Talpi lágyrész-hiány pótlása ALT lebennyel

Soft tissue defect of the sole is usually a quite challenging problem. In this case report the most frequently used reconstructive options of this problem are reviewed paying particular attention for the well applicable and reliable types. An ALT graft as a free flap to the sole offers a good possibility for coverage, which is resistant enough to mechanic strains.