Endoscopic Carpal Tunnel Release

Conventional open carpal tunnel release surgery is one of most successful procedures in hand surgery and has been demonstrated to be an effective treatment for carpal tunnel syndrome. However, a known sequelae in some individuals who undergo the procedure is “pillar” pain. In an effort to avoid this condition and help people return to work more quickly, the endoscopic technique was developed. Endoscopic carpal tunnel release offers a minimally invasive alternative to other traditional techniques with similar outcomes. By placing the incision proximal to the transverse carpal ligament there is potential for decreased scar sensitivity and pillar pain. The technique is technically demanding. The superficial palmar arch and common digital nerve to the ring and middle fingers are at risk for injury during the procedure. With adherence to anatomical landmarks and the proper visualization, the surgery may be safely performed.

Latissimus Dorsi Flap for Leg Reconstruction

Variants of the latissimus dorsi flap are quite versatile and offer multiple reconstructive options for creative surgeons. The latissimus dorsi flap may be raised as a muscle flap or together with the overlying skin as a musculocutaneous unit. Apart from its use as a pedicled flap or for microvascular free flap transfer, the latissimus dorsi can be raised with portions of ribs and may include the serratus anterior muscle. Different customized chimeric (muscle and perforator flap) or perforator flap techniques find application for repair difficult with large three-dimensional defects or when large and thin, skin-only tissue is needed, respectively. Different designs of the flap, dissection techniques, and flap variant applications in the context of a systematic approach to reconstructive problems are described.

Gracilis Flap for Perineal Reconstruction and Functional Restoration for the Treatment of Fecal Incontinence

Preoperative evaluation and management of complex perineal wounds must account for any history of previous surgery, radiation, or trauma; the size and surface area following resection or debridement; and the loss of function or structural integrity. The gracilis muscle or myocutaneous flap is a local, well-vascularized option suitable for perineal soft tissue reconstruction, particularly for moderately sized defects of the groin. The use of functional gracilis muscle for anal sphincter reconstruction may also be considered for the treatment of fecal incontinence due to significant neurologic, traumatic, or iatrogenic injury, as well as for congenital abnormalities.

DIEP and Muscle Sparing Breast Free Flap

The deep inferior epigastric perforator (DIEP) and muscle-sparing (MS) free transverse rectus abdominis musculocutaneous (TRAM) flaps are arguably the most common flaps used for autologous breast reconstruction. The benefit of these flaps is that very little to no donor site muscle is harvested. The decision to use one or the other is occasionally made preoperatively based on body habitus but often intraoperatively based on the quality of the perforating vessels. The technical aspects of the operation are similar except for the actual dissection around the perforating vessels. Studies have demonstrated no significant differences in outcome when comparing the DIEP and MS free TRAM flaps.

Mastopexy

Mastopexy is a skin tightening procedure to restore shape to the ptotic (sagging) breast. Patients must be willing to accept scars as a tradeoff for improved shape. Various patterns of skin tightening procedures are available with the Weiss pattern still being the most commonly used procedure. Patients must be assessed carefully preoperatively and have realistic expectations for scars and recurrent ptosis over time. Patient satisfaction is usually very good in the properly selected patient. The authors emphasize the importance of assessing the patient’s needs as carefully as possible so that both patient and physician are satisfied with the outcome of surgery.

Microtia Repair

Microtia may occur as an isolated finding or in conjunction with other associated anomalies or a genetic syndrome. Ear reconstruction for these patients is typically performed no earlier than 6 years of age. In this chapter, a staged autogenous method of ear reconstruction is described using costal cartilage. In the first stage, a costal cartilage graft is harvested and placed. The next stages involve lobule transposition, detachment of the auricle with placement of a posterior skin graft, and further refinement of the external ear landmarks with tragus creation and definition of the conchal bowl and ear canal.

The Radial Forearm Flap

Radial forearm free-flaps (RFFF) offer great utility in the reconstruction of intraoral soft tissue defects. The use of a free tissue transfer with the radial forearm flap can obviate poor wound healing and replace previously irradiated tissue with well-perfused normal fascia and skin. Considerable care must be taken by the surgeon to preserve adequate function of speech and swallow, as well as to obtain good cosmesis. Knowledge of proper anatomical orientation and preoperative marking provide keys to a successful flap dissection and intraoral reconstruction. After reading this chapter, the reader should have an understanding of the assessment of intraoral defects, indications for RFFF, intraoperative techniques, and marking, as well as postoperative patient management.

Nasolabial Flap

The nasolabial flap is primarily used for nasal reconstruction and most frequently for full-thickness alar reconstruction due to the tissue’s location, texture, color, and bulk. The inferiorly based flap is most often used for alar reconstruction, while the superiorly based flap may also be used for nasal sidewall as well as alar reconstruction. Regardless of whether the flap will be superiorly or inferiorly based, the critical component of the patient marking is placement of the medial incision in the nasolabial or nasofacial crease. In the younger patient, consideration must be given to the donor site scar.

Brachioplasty

Massive weight loss (MWL) patients often present with fairly extensive excess skin of the upper arms. The excess is located in the posterior axillary roll and the Aly posterior brachioplasty technique is designed to eliminate as much excess tissue as is required to create an arm contour that follows the normal underlying musculoskeletal anatomy. One of the major contributions that the author feels he has made to brachioplasty surgery is the delineation of the posterior axillary fold and its extension onto the upper arm as the deformity encountered in all MWL patients. Presurgical assessment and markings, as well as execution pearls are shared with the reader. Sample results and potential complications are discussed.

Liposuction of the Hips and Thighs

Liposuction of the hips and thighs is one of the most requested areas in any cosmetic practice. Proper patient selection, planning, and precise execution of the surgical plan will avoid complications and unhappy patients. The main caveats is to think in a three-dimensional manner when marking the patient and performing the procedure. Using the prone, lateral, and supine positions allows a circumferential contouring of this area. Adequate compression postoperatively gives the best chance for skin contraction. Like any liposuction procedure, the plastic surgeon must remember that what matters is what is left behind to give an aesthetic contour and not how much fat is removed.