Israel Medical Association Journal

Background: The forehead and scalp play a crucial role in the aesthetic appearance of the face. Extensive oncological resections that result in significant defects create challenges for reconstruction and require various surgical techniques.

Objective: To present the planning and surgical technique required for a simple, reproducible one-stage flap to reconstruct an extensive forehead defect.

Methods: A cohort of six patients underwent reconstruction of large anterior forehead or scalp defects using a one-stage axial fasciocutaneous flap. All procedures were conducted under general anesthesia. The defects resulted from tumor resections. The sizes ranged from 5.5 cm to 11 cm. The flap was used to reconstruct various forehead and anterior scalp regions.

Results: All the flaps were successful. The aesthetic outcomes were favorable, and no significant complications were noted.

Conclusions: The extended forehead flap is a versatile option for safe, simple, and reproducible one-stage reconstruction of large forehead and anterior scalp defects that yields satisfactory aesthetic results.

Background: The incidence of autologous breast reconstruction has been steadily increasing in recent years. Deep inferior epigastric perforator (DIEP) flap reconstruction is considered the gold standard for breast reconstruction despite its demanding technical expertise, time intensiveness, and rigorous postoperative monitoring.

Methods: We retrospectively collected data from 102 DIEP flaps utilized for breast reconstruction in 70 patients treated at private clinics between 2013 and 2024. All surgeries were performed by a single, experienced surgeon.

Results: The mean age at surgery was 42.2 ± 8 years. Immediate reconstructions were conducted in 34 patients (48%); 46% of patients had prior radiation therapy. Only one patient received adjuvant radiation therapy. Free DIEP flaps vascularized by one (53%), two (32%), or three (10%) perforators were preferentially anastomosed to the internal mammary vessels. One patient underwent a muscle-sparing procedure due to the absence of available perforators. Total flap failure occurred in four cases (3.9%), three occurred as a unilateral loss in patients who underwent bilateral reconstruction. Postoperative revisions of the microvascular anastomosis were performed in three patients, with successful flap salvage in two (67%). Fat necrosis was diagnosed in 26 breasts (25%), only a minority of cases required follow-up surgery. All patients were managed completely in a private clinic, with none requiring hospitalization in the public system.

Conclusions: Free DIEP flap breast reconstruction necessitates meticulous surgical planning, a well-coordinated surgical team, and close postoperative monitoring. Nevertheless, this surgery can be safely and effectively performed in a private clinic setting, with complication rates comparable to that of the public setting.

Background: There are several methods for primary breast reconstruction following oncologic resection, including alloplastic and autologous-based reconstruction. Major complications that can lead to re-operation and reconstruction failure occur in up to 25% of the patients and necessitate salvage procedures.

Objectives: To present the authors' experience using a pedicled latissimus dorsi (LD) flap for the salvage of complicated and impending failed breast reconstruction.

Methods: A retrospective cohort study was conducted of all patients who underwent breast reconstruction salvage by means of an LD flap in our institution during a 5-year period. Demographic, oncologic, surgical, and postoperative data were collected and analyzed.

Results: Seventeen patients underwent breast reconstruction salvage with the LD flap. Fourteen patients had alloplastic reconstruction and three patients had autologous reconstruction. Postoperative complications included wound infection in three patients, minor wound dehiscence in two, and donor site seroma in two. One case of postoperative infection required re-operation with exchange of the implant with a tissue expander. All breast reconstructions were salvaged using the LD flap. Only one patient complained of functional limitations in using the arm of the harvested LD.

Conclusions: The LD flap is a valuable and reliable flap for alloplastic or autologous breast reconstruction salvage and has a high rate of salvage success despite the challenging surgical environment. This flap offers a good cosmetic reconstruction outcome with relatively low donor-site morbidity and high patient satisfaction.

Background: Tissue expansion is a well-recognized technique for reconstructing a wide variety of skin and soft tissue defects. Its application in the pediatric population has enabled the plastic surgeon to achieve functional and aesthetic goals that were previously unobtainable.

Objectives: To review the use of tissue expansion in the pediatric population, with particular emphasis on indication, operative technique, regional considerations and how to avoid complications.

Methods: We retrospectively reviewed data on 103 expanded flap reconstructions performed in 41 pediatric patients during the period 2003–2006. Tissue expanders were placed on a subcutaneous plane above the fascia and inflated weekly. The expanded skin was used as a transposition flap or a full thickness skin graft for the reconstruction of the involved area. Forty-three tissue expanders were inserted to the head and neck in 21 patients, 45 were inserted to the trunk in 13 patients and 15 were inserted to the groin and lower extremity in 8 patients. Twenty-eight patients had one round of tissue expansion, while 13 patients had two to six rounds. A plastic surgeon, medical student and a lawyer reviewed the patients' photographs and evaluated their aesthetic outcome:

Results: Eighty-six percent of the head and neck reconstructions and 40% of the trunk and extremity reconstructions were graded as having excellent aesthetic outcome, and 11% of the head and neck reconstructions and 37% of the trunk and extremity reconstructions were graded with good aesthetic outcome. The remaining patients were graded with moderate outcome. None of our patients was graded as poor aesthetic outcome. Complications included infection in 6 patients (6%), extrusion in 3 (3%), hematoma in 2 (2%), flap ischemia in one patient (1%), and expander perforation after percutaneous stabbing in one patient (1%).

Conclusions: Tissue expansion is an efficient and valuable technique for reconstruction of large skin lesions and scars.

Background: The most frequent cause of defect in the mandible is tumor-related surgery. Larger defects or anterior arch defects cause severe morbidity due to disturbances in function and aesthetics.

Objectives: To assess the outcome of free tissue transfer for mandible reconstruction.

Methods: Since 1998 we operated on 11 patients with mandible defects using the fibula flap as the reconstruction method. We performed immediate reconstruction in eight patients after ablative surgery, and late reconstruction due to radiation-induced complications in three.

Results: All patients achieved good functional and aesthetic outcome. During the follow-up period two patients died of their malignant disease and one patient died from a non-related cause. Although two patients underwent reoperation in the first 3 months after their primary operation due to fixation failure, there were no other major complications.

Conclusions: According to the literature and our limited experience, the fibula flap is a safe and reliable option for mandible reconstruction.
 

Background: Coverage of part of a soft tissue defect in the thumb, without bone shortening and without long-lasting immobilization in an inappropriate position leading to stiffness, is difficult to achieve.

Objectives: To report our experience using Foucher’s modification of the first dorsal metacarpal artery flap for thumb reconstruction in 21 cases.

Methods: Foucher’s flap is based on the neurovascular structures of the first dorsal metacarpal artery flap and radial nerve-sensitive branches on the dorsum of the second metacarpal and proximal phalanx. The cause of injury was work-related in all 21 cases. The patients' mean age was 37 (range 17–68 years), and mean follow-up was 19 months (range 12–31). Emergency surgery was performed in 13 patients, with a time delay after injury of 4–12 hours. The minimum defect was 12–18 mm and the maximum 20–40 mm. Pedicular length was 55–95 mm. A skin bridge was left intact in 16 cases. In two cases of early postoperative venous congestion and flap loss, a cross-finger flap was performed as a salvage procedure.

Results: Subjective satisfaction score was 8.37/10 (range 4–10); cold intolerance was experienced in 60% and dysesthesia in 33%. All except one patient are able to use their thumb in daily activity. Loss of mobility in the proximal interphalangeal joint of the index finger was less than 20 degrees. Semmes-Weinstein sensitivity evaluation score was 3.61–4.31 on the flap and 0–6.65 on the donor site. Two-point discrimination was 10.8 mm (range 8–20). Grip strength was reduced by 15% compared to the unaffected hand (hand dominance was not taken into consideration). Rehabilitation was not consistent as almost all the patients were living in another location.

Conclusions: First DMCA[1] pedicle flap is a successful thumb reconstruction method, especially in patients not disturbed by its cosmetic appearance.

__________________________

[1] DMCA = dorsal metacarpal artery