A novel modification of Bardach’s two-flap palatoplasty for the repair of a difficult cleft palate

Bardach described a closure of the cleft utilizing the arch of the palate, which provides the length needed for closure and is most effective only in narrow clefts. Herein, we describe a case where we utilized Bardach’s two-flap technique with a vital and easy modification, done to allow closure of a wide cleft palate and to prevent oronasal fistula formation at the junction of the hard and soft palate, which are otherwise difficult to manage with conventional flaps. The closed palate showed healthy healing, palatal lengthening, and no oronasal regurgitation. We advise using this modification to achieve the goals of palatal repair in difficult cases where tension-free closure would otherwise be achieved with more complex flap surgical techniques, such as free microvascular tissue transfer.

Retalho Livre Anterolateral da Coxa para Tratamento de Quelóide Esternal

Hypertrophic and keloid scars represent hyperproliferative disorders that can have a significant impact on patients’ lives. The authors present the case of a 53 years-old male with a sternal keloid after excision of a sebaceous cyst and multiple sessions of steroid infiltration, with worsening of the lesion. The patient underwent complete excision of the scar and reconstruction with an anterolateral thigh flap - ALT. The postoperative period was uneventful, with no signs of relapse. Keloid scar treatment in sternal area implies a reconstruction with no tension, in order to avoid relapse. Treatment of this type of scars is complex and a challenge to the plastic surgeon. In this case, a microvascular tissue transfer was used to reconstruct the large defect that ultimately resulted after scar excision, in a tension-free manner.

Anatomical Study of a Chimeric Fascio-Osteomyocutaneous Fibula Flap for Free Microvascular Tissue Transfer

Background Functional restoration in reconstructive surgery can require complex and adaptable approaches. In this anatomical study, the combined angiosome of the septofasciomyocutaneous vessels originating from the fibular artery was defined as basis for a chimeric flap of the lateral lower leg. Methods Methylene blue injection into the fibular artery was performed in 10 legs of fresh cadavers for visualization of the angiosome on the skin, fibula, and adjacent muscles as the lateral hemisoleus (HS) muscle. With regards to clinical specifications a maximum-size flap containing cutaneous, osseous, and muscular elements was raised. During dissection, the distribution pattern, number and size of stained septofasciomyocutaneous vessels at the lateral border of the proximal, middle, and distal thirds of the fibula length, as well as the flap dimensions were evaluated. Results In all specimens, vessels originating from the fibular artery and supplying the resected fibular bone, the fasciocutaneous flap and dorsally located muscles were found. The mean number of vessels to the skin was 4.2 per leg with a mean diameter of 1.1 ± 0.5 mm (range: 0.4–2.5 mm) and to the HS muscle 3.4 vessels with a mean diameter of 1.2 ± 0.7 mm (range: 0.3–3.0 mm). A total of 88.4% vessels occurred in the proximal and middle thirds of the legs. The resected fibula graft had a mean length of 23.8 ± 3.9 cm (range: 19.9–31.0 cm) and the skin paddle had a mean size of 23.8 ± 3.9 cm (range: 19.9–31.0 cm) × 7.0 cm. The flexor hallucis longus (FHL) muscle had a mean volume of 37.2 ± 15.8 cm3 (range: 18–58 cm3) and the lateral HS muscle 77.1 ± 23.3 cm3 (range: 48–105 cm3). Conclusion Our results and anatomical descriptions indicate that chimeric fibula flaps can meet the specific reconstructional requirements of complex and large sized defects representing a promising basis for further studies.

One of the Highest World Privileges

Royal College of Surgeons of Edinburgh (RCSEd) is one of the oldest surgical corporations (professional oragization) in the world and traces its origins to 1505 [1]. The ad hominem fellow distinction is the most prestigious designation a surgeon can receive from the college. Of the more than 10,000 U.S. surgeons in his specialty, Rui P. Fernandes, MD, DMD, is just the third to be inducted as one (Fig 1) [2]. Consulting Editor of the highly prestigious Journal Oral and Maxillofacial Surgery Clinics of North America. Textbooks: Local & Regional Flaps in Head & Neck Reconstruction: A Practical Approach (Fernandes) – published in 2014; Oral, Head & Neck Oncology & Reconstructive Surgery (Bell, Fernandes, Andersen) – published in 2017. Co-author in the cutting-edge articles: Outcomes of total or near-total lip reconstruction with microvascular tissue transfer; Margin analysis: sarcoma of the head and neck; The cervicofacial flap in cheek reconstruction: a guide for flap design; Alternative approach in mandibular reconstruction for benign disease [3-6]. The list goes on. He don’t stop to relax. He continue to do that again, and again, and again... To move a surgery forward.

Management of Microsurgical Patients using Intraoperative Unfractionated Heparin and Thromboelastography

Background Maintaining optimal coagulation is vital for successful microvascular tissue transfer. The viscoelastic thromboelastography (TEG) is a modern and dynamic method to assess a patient's coagulation status. The aim of this study was to evaluate its diagnostic capabilities of identifying microvascular complications. Methods A retrospective chart review was conducted for the most recent 100 cases of abdominal free flap breast reconstruction of a single surgeon. Patient demographics, medical history, clinical, and operative details were documented. Thrombocyte counts, prothrombin time (PT), activated partial thromboplastin time (aPTT), and various TEG parameters were gathered for preoperative, intraoperative, and two postoperative time points. Results A total of hundred patients were identified, who underwent 172 abdominal-based free flaps for breast reconstruction. TEG was more dynamic compared with PT or aPTT and demonstrated borderline hypocoagulate values intraoperatively upon unfractionated heparin administration and hypercoagulate values postoperatively. In contrast, PT and aPTT demonstrated a continuously hypocoagulable state. Complications included five thrombotic events and three hematomas. The thrombotic cases had much steeper increases of TEG-G between surgery and postoperative day 2 (p = 0.049), while PT and aPTT failed to identify these patients. Of those, two resulted in flap loss (1.2%) that both occurred in patients with abdominal scars from previous surgery. Conclusion The TEG is a useful adjunct for monitoring coagulation status in microsurgical breast reconstruction. When thrombosis at the anastomosis occurs, TEG correlates with a more rapid rebound from an intraoperative hypocoagulable state to a postoperative hypercoagulable state, when using the TEG. The TEG is a valuable tool for a more dynamic assessment of the patients' changing coagulation status.

The role of microvascular tissue transfer in severe limb trauma

Background: Lower extremity reconstruction is an essential part of plastic surgery and focuses on the treatment of wounds. The restoration of an intact covering is the primary surgical requisite following trauma of the lower extremity because deep healing can be no better than the surface covering. Present study will review the field of lower extremity reconstruction focusing on the micro-vascular tissue transfer for severe limb traumatic injuries.Methods: Patients were fully evaluated and defect was assessed depending on the defect requirement free micro- vascular flap was planned. 20 micro vascular flaps in 18 males and 2 females were used for the wound / defect of lower limbs following trauma.Results: There were 18 men and 2 women with a mean age of 43.6 years (range, 18-62 years) in the present study. The overall survival of the flaps was 95% (19/20).Conclusions: The free flap is an effective method of lower-extremity reconstruction. Good outcomes can be achieved with complete debridement and the selection of appropriate recipient vessels and flaps according to the recipient site.