Seminars in Plastic Surgery最新文献

Reconstruction of the eyelid is a complex process that requires an understanding of eyelid anatomy and various reconstructive techniques to restore function and appearance. The eyelids, essential for globe protection, moisture retention, and expression, contain the lacrimal system and intricate musculature that make reconstruction challenging. Tumor excision commonly results in defects in the eyelid that require careful reconstructive planning, with consideration for defect dimensions, location, and involvement of surrounding tissue. This review presents reconstructive techniques commonly used in the management of eyelid defects.

Mohs micrographic surgery (MMS) is a tissue-sparing skin cancer resection technique that involves 100% margin analysis. This procedure is performed in the outpatient setting under local anesthesia by dermatologic surgeons who act as both the surgeon and the pathologist. The technique allows for prompt reconstruction immediately after cancer clearance and offers the highest cure rate for many skin malignancies, including basal and squamous cell carcinoma, as well as more rare tumors. Mohs surgery effectively ensures cancer clearance while minimizing defect size and optimizing cosmetic and functional outcomes for patients. Herein we will discuss the evolution, procedure, and indications of MMS.

Facial reconstruction following Mohs excision presents many challenges. The unpredictable nature of Mohs surgery can yield surprising deficits that require far more extensive reconstructions than originally anticipated. It is up to the reconstructive surgeon to guide the patient through the shock of the excision, initial reconstruction, definitive reconstruction, and postoperative management. It is essential to approach a post-Mohs patient with the understanding that a rushed, same-day reconstruction carries a greater risk for the patient and the outcome than that of a delayed, planned reconstruction. Considering factors beyond the deficits, such as the patient's means, health literacy, and comorbidities, is essential to ensuring a methodical reconstruction with favorable results. Often, deficits will need to be temporized until the patient is optimized and the details of the reconstruction have been established. The specifics of the reconstruction are heavily influenced by the patient's desires, understanding, and ability to participate multistage operations. Once the best suited reconstruction is selected, reviewing expectations and the possible associated contingencies is crucial for patient satisfaction. Despite the surgeon's great effort in ensuring a satisfactory reconstruction, many patients will further benefit from close follow-up and postoperative scar management. The combination of patient optimization, meticulous surgical planning, and postoperative wound management enables the surgeon to obtain favorable outcomes, even in the most unpredictable reconstructions.

The native features of the cheek allow for a variety of approaches when considering reconstruction following Mohs surgery. Selecting the best approach requires consideration of deficit size and location, skin laxity, surrounding anatomy, aesthetic outcomes, and specific patient factors. Reconstruction options vary based on the zone of the cheek affected, but direct closure remains the gold standard. When direct closure is not suitable, the use of the cervicofacial advancement flap, biologic agents, or a combination of the two should adequately address the majority of cheek deficits resulting from Mohs surgery. During cheek reconstruction, great care should be taken to maintain and support the surrounding anatomy, most notably the lower eyelid. Postoperative management is mostly comprised of scar management, as immediate, urgent complications are rare. Options to address postoperative scarring range from silicone sheeting to revisional surgery, but most deficits will settle well if given adequate time and are properly cared for with noninvasive measures.

Given the visibility of the face and the importance of its cosmesis, undesirable results following facial reconstruction present significant challenges for both the patient and the surgeon. Intraoperative measures and postoperative management can ameliorate some unfavorable outcomes, but others may require more extensive intervention. Approaching undesirable results with a frank assessment followed by shared decision-making not only improves outcomes but is also essential for patient satisfaction.

Complex nasal reconstructions require adequate planning with an accurate estimation of the time necessary to perform each stage. Reconstructions of the entire nose, multiple subunits, or a substantial subunit typically require lining replacement and cartilage grafting. Securing the lining prior to a staged reconstruction is preferred, but options such as the Menick folded paramedian forehead flap (PMFF) allow for lining coverage at the time of the first stage. The free radial forearm flap and the PMFF remain the gold standard for the initial lining coverage. Cartilage grafting is fundamental to complex nasal reconstructions and can be secured in either the first or the second stage. Staged reconstructions require thorough patient education, patience from both the patient and the surgeon, and an understanding that final revisions may be necessary.

Relative to other regions of the body, the ear has a high risk of developing cutaneous malignancies that often necessitate Mohs micrographic surgery (MMS) for removal. This procedure can create defects that are immediately noticeable if left untreated. Reconstructive techniques are often needed to restore the appearance of the affected ear and its symmetrical relationship to the contralateral ear. However, achieving optimal aesthetic results can be challenging due to the subtle intricacies of the external ear. Therefore, careful planning and execution should be implemented prior to managing the acquired defect. Additionally, depending on the size and location of the defect, various options aligning with the reconstructive ladder can provide desired outcomes. The purpose of this article was to highlight and discuss the different techniques used in ear reconstruction following MMS.

Computer-assisted surgery is the most significant recent advancement in osseous head and neck reconstruction. Computer-aided design (CAD) software allows computerized planning of resection and reconstruction. Computer-aided manufacturing (CAM) can be used to create models, cutting guides, and patient-specific plates. Several studies have shown that these techniques are more accurate and result in decreased flap ischemia times compared with conventional techniques. CAD also facilitates the immediate placement of dental implants. The most useful application of computer-assisted surgery is delayed reconstruction, in which soft tissue contraction and the absence of a specimen as a reference make accurate estimation of the defect challenging. The drawbacks of CAD/CAM are lack of intraoperative flexibility and cost. Some centers have created in-house CAD/CAM processes using open-source software and commercially available three-dimensional printers.