Floor plan - 2013 Annual Meeting - American Association for Hand ...

Achieving Aesthetic Results in Facial Reconstructive Microsurgery: Planning and Executing
Secondary Refinements
Institution where the work was prepared: New York University School of Medicine, New York, NY, USA
Pierre Saadeh1; Otway Louie1; Evan Garfein1; Jamie P. Levine2; John W. Siebert1; (1)NYU Medical Center, (2)New York
University School of Medicine
INTRODUCTION:
The use of free tissue transfer to provide bulk and contour in facial deformities including malformations, trauma, radiation, and iatrogenic
injuries is extensively documented. The reconstructive challenges implicit in these complex abnormalities are almost always
addressed in multiple surgical stages. The refinements which turn an acceptable result into an excellent result are essential to reconstruction,
yet have not been comprehensively elaborated. We reviewed our experience and described these refinements.
METHODS:
The charts of 322 free tissue transfer cases (1989-2006) by the senior author were reviewed. Free tissue transfer of a circumflex scapular
variant flap (97%) was performed for the treatment deformities arising from hemifacial atrophy (106), hemifacial microsomia (73), radiation
therapy (39), bilateral malformations including HIV lipodystophy (24 patients; 44 flaps), other congenital anomalies (22), facial palsy
(16), and burns and trauma (22). Lessons learned and standardization of surgical approaches were identified and outlined.
RESULTS:
The following techniques optimize aesthetic outcomes. Revisional surgery planning begins at initial flap operation where, prior to inset,
the flap is stretched to maximal dimensions. The dermis is almost always discarded and this must be complete. Qualitatively, more tissue
is required in the malar region, less elsewhere. The borders of the flap must be interdigitated with recipient tissue. Revision is indicated
in all cases but only after 6 months post-operatively. Flap revisions involve liposuction, sharp debulking, and re-elevation with strict
attention to release of tethering or contracture. A frequent trouble spot is the jawline which requires relatively more debulking and elimination
of overhang. Elevation is followed by advancement, rotation, transposition, and/or turnover. Readvancements need to be overcorrected
and re-inderdigitated, especially into the alar-facial junction, oral commisure, lateral and medial canthus, ear, and eyebrow.
Periorbital reconstruction is always combined with lower lid support. The flap is suspended high on the lateral orbit and a lower lid/infraorbital
sling is created. The lateral or medial canthus may require repositioning. Conventional facelift techniques can augment the result
wherein the flap is treated as a SMAS equivalent. Autologous fat injection is useful after stable results have been achieved, particularly
for perioral and nasal/alar subtleties; it remains our technique of choice for lip augmentation. Severe lip deficiencies are addressed with
a variety of flaps (tongue, lip switch, FAMM, and Abbe [rare]).
CONCLUSIONS:
Often lessons learned the “hard way” were the most instructive. The keys to improving results were continual critical reassessment,
open-mindedness to new approaches, and maintaining aggressive expectations.
Immediate Nipple-Areolar Complex Reconstruction with Inner Thigh (TUG) Flap Microvascular
Breast Reconstruction
Institution where the work was prepared: California Pacific Medical Center, Ralph K. Davies Campus, San Francisco, CA,
USA
Matthew J. Trovato, MD; Karen M. Horton, MD, MSc, FRCSC; Rudolf F. Buntic, MD, FACS; Darrell Brooks, MD;
California Pacific Medical Center
INTRODUCTION:
Creation of the nipple-areolar complex (NAC) is the final step in surgical restoration of the breast. Often considered as a complement
to breast reconstruction, NAC reconstruction is usually completed after an interval of several months, making use of local flaps or composite
graft techniques involving the opposite nipple. Because the position of the NAC is defined from the outset in skin-sparing mastectomy,
immediate reconstruction is possible using the skin paddle of the inner thigh flap. The authors report their experience with
immediate NAC reconstruction using the transverse upper gracilis (TUG) inner thigh flap microvascular transplant.
METHODS:
Once the inner thigh flap has been harvested, the crescentic skin paddle is folded back onto itself to form a standing cone, which is fitted
in the skin-sparing mastectomy pocket. The standing cone is subsequently exaggerated using absorbable horizontal mattress
sutures to create an immediate nipple reconstruction. The upper inner thigh skin naturally has somewhat darker pigmentation than the
skin of the breast. This regularly obviates the need for areolar tattoo, and enables immediate areolar reconstruction with the inner thigh
flap. Patients were surveyed by questionnaire, and measurements and photographic documentation was carried out.
RESULTS:
Twelve flaps in 6 patients (mean age 52 years; range 42 to 59 years) were used for immediate breast and NAC reconstruction between
2005 and 2007. Retrospective review with a mean follow-up of 6.5 months (range, 3 to 15 months) revealed patient satisfaction by means
of questionnaire and physical examination. One hundred percent of patients were pleased with their breast reconstruction. Eighty-three
percent were satisfied with breast symmetry, 83% with size, 100% with shape, and 100% with softness/quality of the reconstructed breast.
Every patient would recommend this type of breast reconstruction to a friend. Seventy-five percent of patients were pleased with their
nipple and areolar reconstruction. Clinical examples and projection measurements of reconstructed nipples at a minimum of 6 months
postoperatively will be presented.
CONCLUSIONS:
Immediate NAC reconstruction with the inner thigh (TUG) flap produces reliable and aesthetically superior results. Shape and projection
make this flap an excellent choice in selected patients requiring breast reconstruction. NAC reconstruction with the inner thigh flap
offers an additional potential advantage for breast reconstruction: completion of the entire reconstruction in a single procedure.
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