[download Pdf] Local Flaps In Facial ((HOT))
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Forty-nine patients with skin tumors in the medial canthal area were operated on from 1986 to 1992. Forty-one of 43 surviving patients (95%) could be re-examined with an average follow-up of two years. In 20 patients, a full-thickness skin graft was used for the immediate reconstruction, in 21 patients a local flap, and in a further 8 patients, both methods were used in combination for the surgical repair. The histology of the lesions was mainly basal cell carcinoma; these may show aggressive extension in the medial canthal region. With the high accuracy intraoperative frozen section, immediate reconstructive surgery was performed after surgical excision. The results of the medial canthal reconstruction, using local flaps or full-thickness skin grafts, were compared in terms of the final functional and cosmetic result. The size and depth of the defect after eradication of the tumor was taken into consideration.
A 12-year-old Irish boy suffered a near total facial burn as a toddler when his Halloween costume caught fire. Eleven prior surgeries for correction of lip and eyelid ectropion were marginally successful. On initial exam, dense keloid scars were present over the entire face, chin, jaw, and neck (Fig. 2a). Central elements (the nose and upper lips) were predominantly spared. On profile, dense bands of contracting scar extended obliquely across the cervicomental angle causing substantial retrusiveness of the chin (Fig. 2b). The lower lip was foreshortened and evaginated with exposure of lower dentition and the dento-alveolar ridge. Multi-stage autogenous facial reconstruction was accomplished by MV free transfer of a patterned radial forearm to the neck (Fig. 3) followed by bilateral sequential patterned scapular free flaps to the right and left hemiface/cheeks, respectively (Fig. 4). Architectural modifications were coordinated with each of the flap transfers. A bimalar fascia lata sling was inset during neck reconstruction to elevate the lower lip (Fig. 5). A Porex chin implant provided the chin thrust. Fascia lata slings from the malar arches to the lateral lip modioli were placed beneath each of the scapular flaps for lateral lip support (Fig. 6). All autogenous free flaps were 100 % successful. Additional aesthetic refinements included modest debulking of the cheeks, lower lid canthoplasties, dermal plication of the nasolabial creases, and laser resurfacing of the scars. Six months after the final surgery, facial planes are restored and flaps are well incorporated into the facial geometry with seam hidden at junctions of the aesthetic units (Fig. 7a). On profile, neck contraction is mitigated; cervicomental angle is acute; and chin projection is restored (Fig. 7b).
Case 1. A 12-year-old Irish boy with near total facial burns. a Pre-op frontal. Dense keloid scars on both cheeks, lower lip, chin, neck, and jawline. b Profile. Scar contracture neck and markedly retrusive chin. (Reprinted from Rose EH. Pre-patterned, sculpted free flaps for facial burns. In: Hyakusoku H, Orgill DP, Teot L, Pribaz JJ, Ogawa R (eds). Color Atlas of Burn Surgery. Heidelberg: Springer; 2010)
Case 1. a Intraoperative keloid resection of neck aesthetic unit. b Design of patterned radial forearm flap. (Reprinted from Rose EH. Pre-patterned, sculpted free flaps for facial burns. In: Hyakusoku H, Orgill DP, Teot L, Pribaz JJ, Ogawa R (eds). Color Atlas of Burn Surgery. Heidelberg: Springer; 2010)
Case 1. a Keloid excision LT cheek unit. Doppler auscultation of facial vessels. b Design of pre-patterned scapular flap. Hash marks refer to intraoperative sculpting. Doppler auscultation of superficial circumflex scapular vessels. c Keloid excision RT cheek unit. d Design of pre-patterned scapular flap. (Reprinted from Rose EH. Pre-patterned, sculpted free flaps for facial burns. In: : Hyakusoku H, Orgill DP, Teot L, Pribaz JJ, Ogawa R (eds). Color Atlas of Burn Surgery. Heidelberg: Springer; 2010)
Case 1. Post-operative at 1 year after last surgery. a Facial contours restored with sculpted free tissue transfers. Color hues resemble normal facial skin. Seams hidden at junctions of aesthetic subunits. b Profile. Acute cervicomental angle restored. Good chin shape and projection. (Reprinted from Rose EH. Pre-patterned, sculpted free flaps for facial burns. In: Hyakusoku H, Orgill DP, Teot L, Pribaz JJ, Ogawa R (eds). Color Atlas of Burn Surgery. Heidelberg: Springer; 2010)
Touch-based simulation provided an efficient and superior method of learning three different local flap techniques for facial soft tissue reconstruction, and helped recalling steps involved in the surgery in a fluid manner that also improved task performance.
We have developed BaSSiS (Basic Skin Surgery Interactive Simulation), a novel, interactive touch-based mobile simulation App for tablets and smartphones that educates facial skin lesion resection and concepts pertaining to basic skin surgery and local flap reconstruction. A prospective, randomised educational trial was conducted to compare the educational efficacy of this novel mobile simulation App.
Selected students underwent simple randomisation and were assigned to learn local flaps either using the online text-based self-study module (non-intervention control arm) for 2 h or the mobile simulation App (intervention arm) on the iPad tablet for 1 h. The volume and quality of literature reading was equally provided to both groups. Content included details about skin anatomy, relaxed tension lines and facial regions. There was an emphasis on pathology, including basal cell and squamous skin cancers, alongside the latest treatment guidelines from the British Association of Dermatologists. Relevant papers explaining the classification of local flaps and design pertinent to facial reconstruction were provided. Surgical etiquette, names of instruments and safety instructions for handling of instruments, was also included. Both learning experiences took place in supervised, designated seminar rooms at Chelsea and Westminster Hospital, London, UK. Participants were requested to not study any related material outside the allocated learning session.
Students were invited, approximately 1 week after their learning sessions, to complete a multiple-choice question (MCQ) assessment. The assessment was generated in line with the study material provided to both groups and verified by two consultant surgeons who were independent from the study. The assessment consisted of 33 questions that assessed both anatomical and procedural knowledge pertaining to facial local flap surgery and repair. Participating students were also asked to undertake a task-based assessment on pig skin tissue models to assess surgical skill acquisition and performance. This was conducted in the Centre for Clinical Practice at Chelsea and Westminster Hospital, London, UK. The task-based assessment was rated by a plastic surgeon (MK) who was blinded to the allocation of participants. The performance of each participant was measured according to an Objective Structured Assessment of Technical Skills (OSATS) rating scale derived from a validated procedural task analysis mark sheet based on bench models (Table 2) [9]. Each participant was marked from 1 to 5 on the scale across the ten domains, and the final score was an average of the total achieved, marked out of 5.
Our study investigated the efficiency and educational benefit of using a touch-based interactive mobile simulation App (BaSSiS) in teaching medical students the basics of facial skin surgery and anatomical concepts pertinent to local flaps. In practice, skin surgery for common lesions is often carried out by a variety of health care specialties including general practitioners, dermatologists and surgeons [18]. A recent study found that adequate training was a key factor in successfully diagnosing and treating skin lesions with appropriate resections with a low rate of recurrence [18]. Resection of facial skin lesions is also notoriously associated with the highest rate of incomplete excisions and most frequent recurrence [19, 20]. A thorough understanding of skin lesions, and demonstrating skill in excising and appropriately closing the surgical wound, is an integral component of the core surgical training curriculum [21] that may be supported by mobile simulation Apps such as BaSSiS.
Limitations existed despite our best efforts in creating and following a rigorous and robust study protocol. Although we emphasised to all participants that reading around the subject was not allowed outside the allocated educational sessions, we were unable to ensure that participants did not read more about skin surgery and local flaps. The relatively low scores obtained are likely to be due to the students selected being complete novices who had not been exposed to skin surgery concepts, had not completed any basic surgical skills training courses prior to the study and had not receive any procedural skills training during the study. The fact that the OSATS scoring system was designed to assess performance of surgeons in training, and the interval between learning and testing was 4 weeks, could also have contributed to further loss of scores in marking. The final assessment OSATS scoring system was derived from a validated bench model assessment and was modified to fit the progression of advancement flap and rotational flap as designated in the simulation software. This may have disadvantaged the control group, who were learning the operative steps from independent literature not directly linked to a task analysis. Lastly, the small sample size and the small difference in average scores, though statistically significant, highlight the need for further evaluation and testing through larger studies that also include surgical trainees.
The BaSSiS interactive mobile simulation App showed a statistically significant improvement in both MCQ and Task Analysis average scores for novice students learning about basics of facial skin surgery and local flaps. It provided an efficient method of learning three different local flap techniques for facial soft tissue reconstruction and helped in recalling steps involved in the surgery in a fluid manner. 2b1af7f3a8