secondary wound healing mechanism in the treatment of the pilonidal sinus: a clinical trial

Background

The most important step in treating a pilonidal sinus is eradication by surgical excision. Over the years, various surgical techniques have been reported for wound closure, yet their management still poses a challenge. The current study compares the results of two different methods of wound management: secondary wound healing versus the Z-plasty surgical technique.

Material and method

The current clinical trial recruited 84 uncomplicated pilonidal sinus patients who were to undergo complete surgical excision of the pilonidal sinus. For wound healing, the 84 subjects were equally divided into two groups of 42 patients each. One group was selected for Z-plasty surgical wound closure and the other for the secondary healing mechanism. Outcomes measured consisted of demographic data, length of operation, complications, severity of pain, number of dressings, recurrence, and complete healing time.

Result

Age or sex distribution and the median BMI (kg/m²) did not significantly differ between the two groups. The length of the operation for Z-plasty subjects was significantly longer (P <0.0001). The median number of dressing changes for secondary wound healing patients was 38.69, which was significantly higher than the 4.95 dressing changes for the Z-plasty group. The total time recorded for complete wound healing was 21.61±4.27 days in the Z-plasty group and 41.23±24.28 days for secondary wound healing subjects, which was statistically significant. Twenty-four hours postoperation, patients in the secondary wound healing group had significantly more pain, and the Visual Analogue Scale scores of the Z-plasty and secondary wound healing groups were 3.42±0.76 and 6.09±1.2, respectively. Concerning the recurrence rate, there were no significant differences between the two groups. SPSS version 22 performed the analyses, and the independent t-test compared the continuous variables. A P value less than 0.05 was considered statistically significant.

Conclusion

Z-plasty is a safe and effective procedure in terms of wound complications and recurrence rate. This method is also cost-effective and better received by patients.

A novel surgical correction using a combination of wave-like incision and Z-axis Z-plasty for congenital constriction band syndrome

BACKGROUND

A congenital constriction band (CCB) is a relatively common anomaly among limb malformations. However, the number of cases treated at a given center is limited and differences in techniques used by surgeons at each facility have a significant impact on the treatment outcomes. Several surgical methods have been reported, but a standard technique that yields consistent satisfactory results is still needed. Here, we introduce a novel technique for the treatment of CCB syndrome that uses a combination of wave-like skin incision and Z-axis Z-plasty.

PATIENTS AND METHODS

A wave-like incision was used for skin incision with the goals of achieving an accordion effect and a less noticeable post-operative scar. After the fibrous constriction band was completely excised, a Z-plasty of sufficient size in the Z-axis direction was performed on the dermis-inclusive adipose tissue. For over 10 years, this technique was applied to 11 sites in 6 patients. A retrospective study of the characteristics of these cases was performed, including age at surgery, gender, type of deformity, degree of constriction, types of examination, number of surgeries, and post-operative outcomes.

RESULTS

In all patients, a normal contour of the limbs was achieved and the hourglass-like deformity caused by the constriction band was satisfactorily improved. No additional corrective surgeries were needed, there was no abnormal growth of the treated limbs, and scarring was aesthetically acceptable in all cases.

CONCLUSION

The novel technique described here uses deep subcutaneous fat to correct the hourglass-like deformity and restores a normal limb contour, while the wave-like skin incision minimizes post-operative scarring.

Efficacy and safety of surgical excision and reconstruction combined with radiotherapy for huge keloids: A 13-year experience

BACKGROUND

Surgical excision combined with radiotherapy is considered an effective treatment for keloids, while the efficacy and safety of this regimen for huge keloids in patients who need reconstruction after excision is still unclear. Therefore, this study aimed to evaluate the efficacy and safety of surgical excision and reconstruction combined with radiotherapy for huge keloids in a single center with 13 years of experience.

METHODS

All consecutive patients with huge keloids who underwent surgical excision and reconstruction combined with radiotherapy were identified. Demographic information, prior interventions for keloids, parameters and complications, and recurrence rates were documented.

RESULTS

Twenty-one patients (10 males; mean age, 43.19 ± 18.15 years) were included, 14 patients reconstructed with z-plasties, 5 with skin grafts, and 2 with skin flaps. During a mean follow-up of 75 months, one patient developed local necrosis without the need for revision surgery and two patients developed temporary hyperpigmentation. Two patients with the z-plasties suffered partial keloids recurrence, which was healed with corticosteroid injection. No wound infection, hematoma, telangiectasia, or new keloids at donor sites were observed. The overall appearance of reconstructed defects was aesthetically acceptable.

CONCLUSION

Surgical excision and reconstruction combined with radiotherapy may be safe and effective for huge keloids.

Late management of amniotic bands syndrome with incomplete syndactyly: A case report of 4-year-old child

INTRODUCTION

Amniotic band syndrome is a fetal entrapment in strands of amniotic tissue. This condition causes multiple deformities ranging from simple constricting bands to lymphedema, autoamputation, syndactyly and other congenital anomalies. Reconstructive surgery is the main treatment for ABS.

PRESENTATION OF CASE

A 4-year-old male presented with multiple constricting bands affecting both hands in addition to an incomplete syndactyly between the third and fourth left digits. A two-staged operation was performed to repair the deformities with 6 months interval. Series of Z-plasties were used to release the constricting bands and the syndactyly was separated by a web zigzag incision approach and full-thickness skin grafting.

DISCUSSION

Management of ABS must be individualized. The urgency of the surgical release depends on the depth of the constricting bands and their influence on circulation and lymphatic drainage. Superficial bands can be released electively for cosmetic appearance while deep bands should be released as soon as possible. The separation of syndactyly should be done at the first year of life to maintain the digits functionality and parallel growth.

CONCLUSION

This paper emphasizes the importance of early repair of constricting bands associated with syndactyly to avoid the consequences of the delay on digital growth.

The Square-Plus Flap: A Modification to Release Long Postburn Scar Contractures

The square flap method has been successful in releasing contracture bands at various body regions. However, the original square flap method alone may not be efficient in releasing long contracture bands. We, therefore, proposed an extended design to the traditional design, which is called the "square-plus flap." A 4-year-old girl presented with a postburn web-like contracture band over the right axilla. We marked a square flap technique at the center of the contracture band and then two additional Z-plasties were placed on both edges of the flap. After the release and securing of the square flap, the adjacent distal Z-plasty was then transposed and sutured in their new locations. We do not need to incise the proximal Z-plasty as we could achieve complete relaxation of the contracture band. This novel modification can be added to the plastic surgeon's armamentarium for releasing long postburn contracture bands involving distinct body regions.

Refining macrostomia correction: Case series applying square flap technique and Z/W-plasty skin closure for enhanced aesthetic and functional outcome

INTRODUCTION AND IMPORTANCE

Macrostomia is a congenital deformity found in Tessier no. 7 facial clefts defined as an enlargement of the mouth at the oral commissure. Several techniques are described in literature to achieve optimal functional and aesthetic results, with varying results and surgeon preferences. In this case series we report surgical repair of macrostomia with a vermillion square flap method for the oral commissure combined with either Z-plasty or W-plasty closure for the skin.

CASES PRESENTATION

A retrospective case analysis of 12 patients with macrostomia operated over the past 7 years at our plastic surgery division was performed (by two different operators; 11 cases by A.S. and 1 case by R.S.). Clinical features of the patients were analyzed through photography documentation, and patient description such as age of operation, operation technique, and complications were obtained through patient records. Macrostomia was corrected with a vermillion square flap method for commissure, overlapping muscle closure, along with either Z-plasty or W-plasty closure for the skin. Quality of lip commissure position, symmetry, thickness of vermillion, and scar result were recorded.

CLINICAL DISCUSSION

In all twelve patients repaired with the overlapping muscle closure and square flap, the lip commissures were formed with satisfactory shape, position, and thickness with no commissure contracture during the follow up period. The Z-plasty was a simpler method compared to the W-plasty, and resulted in comparable scars. One patient (adult with hemifacial macrostomia and W-plasty skin closure) underwent revision surgery for more accurate symmetry and position of the oral commissure.

CONCLUSION

There are many varieties of surgical repair for macrostomia, and each method should be adjusted and combined according to each patient. Overall, macrostomia repair with this technique combination produced satisfactory aesthetic and functional results in all twelve patients. Z-plasty for skin closure after muscle and vermillion closure was a simpler technique and resulted in comparable scars than W-pasty closure in this case series.

Fingertip coverage with uni-pedicled volar rotational advancement flap with large Z-plasty: a report on 112 cases

BACKGROUND

Simple and safe fingertip reconstruction methods involve the use of local neurovascular islands flaps that can preserve functional length and sensitivity, and reconstruction with skin of the same texture. However, techniques involving flaps have numerous drawbacks and do not satisfy all the requirements for fingertip reconstruction. A particular problem is the persistence of contracture deformity due to lack of full flap advancement. We present a new technique using uni-pedicled volar rotational advancement flap with large Z-plasty, and describe the results of long-term follow-up.

METHODS

From October 1993 to December 2009, 112 fingers of 98 patients were covered with uni-pedicled volar rotational advancement flap with large Z-plasty after sustaining various types of injuries or finger pulp avulsion. A longitudinal incision was made along the lateral border of the digit and a large neurovascular volar flap was elevated just above the pulleys and flexor tendon sheath. To release tension, a large Z-plasty was applied at the metacarpophalangeal joint or interphalangeal joint crease. The final patient outcomes were reviewed retrospectively.

RESULTS

All fingertip injuries were treated without flap necrosis. Partial wound dehiscence was observed in two patients and average static two-point discrimination was 5.2 mm. There were no postoperative contracture deformities, joint stiffness, paresthesia, or hypersensitivity. Most patients were left with acceptable scarring and were free of postoperative pain and cold intolerance during the long-term follow-up.

CONCLUSIONS

Our novel technique provides durable, completely sensate, and well-vascularized coverage of the fingertip with minimal discomfort to patients.

Management of Axillary Contracture in Poland Syndrome: Differentiating Fibrous Band and Skin for Optimal Release

Poland syndrome (PS), an uncommon congenital unilateral aplasia of chest wall muscles, may exhibit rare accompanying signs, such as axillary webbing or contractures. The existing literature on the specific management of axillary contractures is limited. In this report, we present the case of a 10-year-old girl with PS manifesting an axillary web containing a fibrous band, which was successfully surgically corrected by a double-opposing Z-plasty. Our surgical approach entailed a meticulous distinction between the deep fibrous band and the superficial cutaneous layer, guided by histopathological findings that indicated the presence of tendon-like tissue, ultimately yielding excellent outcomes. This report will help expand knowledge by highlighting the unique manifestation of PS and emphasizing the importance of employing appropriate treatment approaches. Moreover, addressing both tendon and skin components is essential for optimal contracture release in PS.

Outcomes of Linear Circumferential Skin Closure for Congenital Constriction Ring Syndrome

Background: Congenital constriction ring syndrome (CCRS) is a rare condition diagnosed at birth characterised by deformation due to a constriction ring. The usual treatment for CCRS involves excision of the constriction ring and suture of the skin incorporating a Z-plasty to prevent scar contracture. A Z-plasty often results in an unsightly scar. In order to avoid this, we performed linear circumferential skin closure (LCSC). The aim of this paper is to report the outcomes of LCSC for CCRS. Methods: We retrospectively investigated all patients with CCRS who underwent LCSC between 2002 and 2020. Two linear incisions were placed proximal and distal to the constriction ring in parallel, and the constriction ring was excised carefully so as not to damage nerves or vessels. The deep subcutaneous and dermis layers were sutured. The skin was closed using adhesive tape. Two-stage surgery was performed in two patients with severe CCRS of the lower leg to avoid problems with distal circulation. Patients were followed up for at least 1 year and assessed for complications and quality of scar. Results: We performed LCSC for 31 sites in 19 patients, including one forearm, 14 fingers, 10 lower legs and six toes. The median age at the operation was 16 months (range: 4-175). The median follow-up period after surgery was 5.8 years (range: 1.9-16.0). The linear surgical scar had healed well in all patients and there were no complications. There was no recurrence of the constriction ring and no scar hypertrophy, though we did not perform fat mobilisation in all cases. None of the patients required additional surgery and the aesthetic outcome of the linear circumferential surgical scar was maintained at the final observation. Conclusions: Treatment for CCRS using LCSC resulted in no complications, no recurrence of constriction and an excellent aesthetic outcome. Level of Evidence: Level IV (Therapeutic).

One-sized bilobed flap does not fit all standing cones: a mathematical analysis of the standing cone in bilobed flap dynamics

The bilobed flap (BLF) is a workhorse for nasal repair. Alterations to the length and orientation of the BLF's standing cutaneous deformity (SCD) have been suggested as a means of preventing Z-plasty-induced flap lengthening and consequent ipsilateral alar depression. To investigate the effect of design variations of the SCD on bilobed flap mechanics. Geometric analysis of the BLF was performed using commercially available graphing software. BLFs were designed with a SCD equal to one radius (rBLF) and one diameter (dBLF) of the primary defect as well as with a more superiorly-oriented one diameter SCD (soBLF). Lengths from the pivot point to the distal edges of the primary defect and primary lobe were measured and compared. Elongation or a more superior orientation of the SCD without changes to the rest of the flap design forms a primary lobe along a shorter arc resulting in insufficient flap length to resurface the primary defect. The insufficient length requires secondary motion to complete the repair and possible unintended alar displacement. Modification of the size and orientation of the SCD alters the location of the pivot point, which is a key determinant of BLF mechanics. Therefore, changes to the SCD require alterations to the remainder of the flap design to ensure aesthetic and functional success.

Local Flap Reconstruction of Burn Contractures in Extremities and Neck: A Nine-Year Experience with Long-Term Outcome Evaluation in Southwestern Iran

Background

Treating burn scar contractures remains challenging for reconstructive surgeons; no clear guidelines declare the optimal and most effective technique. We evaluated the efficacy of local flaps in treating patients with post-burn contractures.

Methods

This retrospective study included 243 patients with post-burn contractures referred to Taleghani Hospital (Khuzestan, southwest Iran) for local flap reconstruction from 2011 to 2020. Patients' demographic data, detailed descriptions of scars, surgical procedures, and flap outcomes were assessed. A plastic surgeon conducted all surgical procedures, the goals of which were to release the scar and cover the defect. Joint range of motion (ROM) (according to goniometric measurements), complications, need for second-stage surgery, and patient satisfaction were assessed.

Results

After scar release, 70.4% of joints were covered with a Z-plasty and similar local flaps, 26.1% with a Z-plasty plus skin grafts, and 3.5% with only skin grafts. The outcome after one year revealed a significant improvement in mean ROM (by 45.80% of the normal ROM; P< 0.001). The mean functional and aesthetic satisfaction scores were 9.45 and 7.61 out of 10, respectively. The complication rate was 10.82%: re-contracture occurred in 3.82%, flap tip necrosis in 1.27%, and partial flap necrosis in 0.31%.

Conclusion

Simple local flaps such as the Z-plasty are safe and effective in covering the joint following post-burn contracture release. Due to the feasibility, minimal need for facilities, steep learning curve, acceptable functional and aesthetic outcomes, and low complication rate, we strongly recommend the Z-plasty for reconstructing burn contractures, particularly in LMICs.

Medial Canthal Reconstruction - Scar Restricting Vision in Only Seeing Eye of a 75-year-old Female

Scarring is a common post-injury outcome that can precipitate functional impairment. We present the case of a 75-year-old female who presented with diminished upper eyelid excursion in her right (only seeing) eye due to scarring associated with a facial laceration. She had a history of right eye corneal transplantation and necessitated urgent excision of the scar to release upper eyelid motion. The scar was excised, and a full-thickness skin graft (FTSG) was used, harvested from the skin of the right supraclavicular neck. Post-operative recovery was excellent, and the patient was relieved of restriction of her right upper eyelid opening.

Overlapping repair and epitenon healing are more stable biomechanically than side to side repair and endotenon healing in achilles tendon lengthening with Z plasty

BACKGROUND

The current study aimed to compare biomechanical stability and healing process of side-to-side repair with overlapping repair after Achilles tendon lengthening with Z-plasty.

METHODS

In our study, 22 Sprague Dawley male rats were used. Side-to-side repairs were classified as group 1 and overlapping repairs as group 2. The left and right legs of seven rats were used to compare early group 1 and early group 2 biomechanical test results at day 0. Seven rats were used to compare late group 1 and late group 2 biomechanical test results at day 28. Both the right and left tendons were tested from the four rats examined in the biomechanically in the untreated control group. The last remaining four rats were used for histopathological evaluation of tendon repair, at 28-days from the index procedure.The ultimate load to failure was compared between groups.

RESULTS

At time 0, there were no measurable differences between group 1 (3.8 ± 1.4 N) and group 2 (3.7 ± 1.1 N), and both could endure less than one-tenth of the untreated control (49 ± 12). At 28 days, ultimate load to failure improved significantly in both group 1 (16.2 ± 3.5 N) and even more in group 2 (36 ± 8.1 N). While there was a significant difference between group 1 and group 2, neither were able to meet the untreated control (49 ± 12). Histopathological evaluation in the post-healing period showed that fibrosis, neovascularization, and inflammation increased in both groups.

CONCLUSION

The overlapping suture technique and epitenon healing have more stability compared to side-to-side suture technique and endotenon healing. Human population trials may or may not exist, our study suggests it should be considered and further investigation needed before actual clinical application.

Buried penis secondary to ectopic scrotum

INTRODUCTION

Ectopic scrotum is a rare clinical entity, potentially associated with other congenital abnormalities. We present the case of a patient with buried penis secondary to ectopic scrotum. The surgical technique was described, and a literature review was carried out.

CLINICAL CASE

1-year-old patient with ectopic right hemiscrotum and the testes within the scrotal sac. A double Z-plasty was performed with two flaps - one above the penis, surrounding the ectopic scrotum, and the other one at the scrotum to modify the bifid scrotum. The upper flap was rotated downwards, which allowed ectopy to be repaired, and the lower flap was used to repair bifidity. No postoperative complications were recorded. Follow-time was 6 months, with good final cosmetic results.

DISCUSSION

Ectopic scrotum is an infrequent congenital malformation. Cutaneous rotation flaps with Z-plasties are a valid treatment option, with good long-term cosmetic results.

Humero-Pectoral Band in Poland Syndrome

The humero-pectoral band in Poland syndrome is a rare presentation and needs urgent surgery because it restricts the shoulder abduction of the patient. In our case, instead of excising the band, we have made use of the tissue by including it in the Z-plasty flaps which make the flaps reliable even though they were supplied by a narrow base.

Retro-Malleolar Z-Plasty of Flexor Hallucis Longus Tendon in Post-Traumatic Checkrein Deformity: A Case Series and Literature Review

Checkrein deformity (CD) is a dynamic deformity of the hallux characterized by flexion contracture of the interphalangeal (IF) joint and extension contracture of the metatarsophalangeal (MTP) joint, worsened by ankle dorsiflexion. It is due to post-traumatic or ischemic retraction of the long hallux flexor tendon (FHL) following soft tissue trauma, leg fractures, ankle fractures and, more rarely, calcaneal or talar fractures. Diagnosis is essentially clinical, associated with imaging, to rule out unrecognized causes and evaluate fracture healing process. Few cases are reported in literature without univocal treatment. Background and Objectives: To analyze clinical and functional outcomes in patients with CD treated with release and retro-malleolar Z-plasty lengthening of FHL tendon. Materials and Methods: Patients diagnosed with CD treated with retro-malleolar (at tarsal tunnel) Z-plasty lengthening of the FHL tendon between January 2016 and August 2020 were included. Clinical and functional outcomes were collected on admission and post-surgery and analysed retrospectively. Patients with a minimum follow-up of 18 months were included. Results: A total of 14 patients, with mean age of 37.4 years old, with CD diagnosis were included in the study. All patients were suffering from post-traumatic CD and the mean time from trauma to onset of deformity was of 7 months (range 1−12). At a mean follow-up of 31.8 months (range 18−48) we found a significant improvement (p < 0.05) in terms of pain relief (VAS), function (AOFAS score) and ROM of the IP and MTP hallux joints. No recurrence, loss of strength, nerve injury or tarsal tunnel syndrome were observed. No patient required revision surgery. Conclusions: In this case series the retro-malleolar FHL tendon Z-plasty proved to be a suitable option for CD correction, allowing a good clinical and functional recovery.

A Case of Traumatic Nasal Valve Stenosis Successfully Treated with Open Rhinoplasty and Z-Plasty

External nasal deformity is common and can be treated surgically. It often occurs in conjunction with the development of the nasal septal cartilage, vomer, and vertical plate of the ethmoid bone but may be caused by trauma. Here, we present a case of external nasal deformity caused by trauma. A woman presented with nasal obstruction due to dysfunction of the nasal valve area and was referred to our department for treatment. No chronic rhinosinusitis or nasal septal deviation that causes nasal obstruction was noted at the initial examination. However, trauma-related scarring was observed in the nasal valve area, and a Cottle test yielded positive results. The patient underwent combined rhino- and Z-plasty surgery and is currently undergoing follow-up at an outpatient clinic.Although otolaryngologists generally use an endonasal approach to treat nasal obstruction, it is important to perform an appropriate evaluation of the external nose and to collaborate with a plastic surgeon, as necessary.

A novel surgical treatment for labial adhesion - The combination of Z- and Y-V-plasty: A case report

Labial adhesion is characterised by complete or partial fusion of the labia minora. It occurs rarely in postmenopausal women. Although various methods have been proposed, there is no established treatment for postmenopausal patients with labial adhesions due to its low prevalence in this age group. Severe cases require surgical intervention, and the postoperative recurrence rate is relatively high at 14-20%. In this study, a novel therapeutic method was designed to treat labial adhesions: a combination of Z- and Y-V-plasty. An 82-year-old woman was diagnosed with severe long labial adhesion during an episode of urinary tract infection. The labia could not be separated manually; hence, Z-plasty was performed on the ventral side and Y-V-plasty on the anal side under general anaesthesia. No recurrence was noted eight months postoperatively. This method is relatively easy and produced the desired therapeutic effect with decreased risk of recurrence. This is a novel approach for postmenopausal patients with severe labial adhesion.

Scar Revisions

Scars pose a complex challenge to the reconstructive surgeon in the variability of their presentation and their effect on cosmesis and function. Numerous surgical and nonsurgical options exist for scar management, each with their respective advantages and disadvantages. Each treatment modality should be tailored to the patient to ensure enhanced outcomes. In this review, we discuss different scar presentations, scar management options, and the benefits and risks with undergoing these various treatment modalities.

The Z-plasty contributes to the coalescence of a chronic non-healing wound

This study aimed to explore the treatment effect of Z‐plasty on a non‐healing wound. A total of 72 patients diagnosed with a chronic non‐healing wound in Peking University Third Hospital from November 2009 to August 2019 were retrospectively analysed. Among them, 27 patients were treated with Z‐plasty, and 45 patients were treated with the general method. Detailed patient information was retrieved from medical records, including age, gender, body mass index (BMI), alcohol, smoking, and comorbidities (diabetes mellitus, hypertension, heart disease). Surgical parameters included operation time and intraoperative blood loss. Wound swelling, epidermal blisters, wound edge colour, and skin temperature at 1 day after surgery were assessed to evaluate the blood supply of the wound. Surgical complications included infection, haematoma, dehiscence, and non‐healing within 2 weeks postoperatively. Student t test (for continuous data) and Chi‐square test (for categorical data) were conducted to determine the statistical difference. We found no significant differences in age, gender, BMI, alcohol, smoking, and comorbidities between the two groups. Z‐plasty did not show any advantages in the surgical time, invasive blood loss, hospital days, and hospitalisation expenses. The incidence of abnormal wound edge colour with Z‐plasty was significantly lower than that with the general treatment (P < .05), and the Z‐plasty enables better healing of the patient's wound (P < .05). Z‐plasty promoted better recovery of chronic non‐healing wounds than direct suturing.

One-stage circumferential limb ring constriction release and direct circular skin closure in amniotic band syndrome: a 14-case series

The aim of the present study was to report results of direct circular suture after 1-stage circumferential resection of limb ring constriction in amniotic band syndrome. A multicentre retrospective study included 14 patients with amniotic band syndrome (mean age, 13.3 months) operated on between 2004 and 2019 by circumferential release of ≥1 ring constriction. Assessment was based on limb function and clinical scar aspect on the POSAS and Vancouver scales. Mean follow-up was 3.9 years. There were no scar-related, vascular or neurologic complications, postoperatively or at last follow-up. POSAS and Vancouver scores were satisfactory. One-stage circumferential release with direct closure is a simple technique that provides satisfactory functional and esthetic results.

Multiple-Layer Lumbosacral Pseudomeningocele Repair with Bilateral Paraspinous Muscle Flaps and Literature Review

BACKGROUND

Pseudomeningocele is an uncommon but widely recognized complication of spinal surgery that can be challenging to correct. When conservative measures fail, patients frequently require reoperation to attempt primary closure of the durotomy, yet attempts at true watertight closures of the dura or fascia sometimes fall short. We describe a technique of lumbosacral pseudomeningocele repair involving a 2-layer pants-over-vest closure of the pseudomeningocele coupled with mobilization of bilateral paraspinal musculature to create a Z-plasty, or a Z-shaped flap. We have demonstrated a high success rate with our small series.

METHODS

The technique used meticulous manipulation of the pseudomeningocele to make a 2-layer pants-over-vest closure. This closure coupled with wide mobilization and importation of paraspinous muscle into the wound effectively obliterated dead space with simultaneous tamponade of the dural tear. The lateral row perforators were left intact, providing excellent vascularity with adequate mobility to the patient.

RESULTS

This technique was incorporated into the care of 10 patients between 2004 and July 2019. All wounds were closed in a single stage after careful flap section based on the wound's needs. We demonstrated successful pseudomeningocele resolution in all 10 patients with no observed clinical recurrence of symptomatic pseudomeningocele after at least 6 months of follow-up.

CONCLUSIONS

This technique provides a straightforward option for the spine surgeon to manage these challenging spinal wounds with minimal, if any, need for further laminectomy as well as a high fistula control rate with minimal morbidity.

Comparison of simple frenotomy with 4-flap Z-frenuloplasty in treatment for ankyloglossia with articulation difficulty: A prospective randomized study

OBJECTIVE

To compare the surgical outcomes of simple frenotomy and the 4-flap Z-frenuloplasty according to the articulation test values and tongue-tie classification in patients with ankyloglossia with articulation difficulty.

STUDY DESIGN

prospective randomized study.

SETTING

Tertiary academic center.

SUBJECTS

and methods: Children with ankyloglossia with articulation difficulty were randomly divided into 2 groups for surgical treatment. Patients were evaluated for the tongue-tie classification and articulation test before surgery. Three months after the operation, the frenulum classification and articulation test were re-evaluated to compare the differences in surgical outcome between the two surgical methods.

RESULTS

Out of 37 patients, 19 underwent the 4-flap Z-frenuloplasty and 18, the simple frenotomy. No differences were observed in the baseline characteristics of the patients assigned to both groups. Changes in the tongue-tie classification and improvement in the articulation test results were observed with both the surgical methods. Both surgical groups had significant improvement in the speech articulation test (consonants) but there was no difference in the speech outcomes between the surgical groups.

CONCLUSION

Although there was no significant difference in the surgical outcome between the two surgical methods, ankyloglossia patients showed improvement in a Korean speech articulation test 3 months after undergoing surgery to release the lingual frenulum.

Plastic Surgery Techniques for Wound Coverage

This article reviews techniques for wound coverage that are not amenable to simple linear closure. The relevant anatomy and classification of flaps is discussed, as well as specific techniques for successful flap design.

Comparative analysis on the effect of Z-plasty versus conventional simple excision for the treatment of sacrococcygeal pilonidal sinus: A retrospective randomised clinical study

Sacrococcygeal pilonidal sinus is one of common diseases in general department. However, it is characterised, for surgeons, by high post-surgical recurrence and high incidence of post-surgical wound complications. Due to that fact, this retrospective randomised clinical study was designed to evaluate the surgical procedure effect of Z-plasty (ZP), compared with convention simple excision (SE). A total of 67 patients from May 2015 to May 2019 in our department were studied into two groups randomly, the group of ZP and the group of SE. The patients' characteristics, surgical data, hospital length of stay (LOS), and post-surgery complications were recorded. Statistical approaches were proceed with P-value analysis. The results are as follows. No significant differences were found between these two groups of the ages, gender distribution, Body Mass Index (BMI), smoking history, diabetes mellitus, and blood hypertension. The estimated blood loss, specimen volume, distance to anus, and drain output on the first day of post-surgery between the two groups were not statistically significant, either. However, surgical time in the ZP group was longer than that in the SE group (P < .0001). LOS in the ZP group was obviously shorter than that in the SE group (P = .0051). Furthermore, the patients of the ZP group were tending to suffer from fewer post-surgical complications than the ones of the SE group. In a conclusion, we hold the point view that the surgical procedure of ZP can lead a better outcome than SE because it demonstrated shortened LOS and fewer post-surgical complications.

Surgical management of midline cervical cleft

INTRODUCTION

Midline Cervical Cleft (MCC) is a midline cervical congenital anomaly that manifests as a vertical cutaneous/subcutaneous defect with abnormal dermal elements as well as an underlying fibrous cord that extends from the sternum to the mentum of the mandible, which can lead to "wry neck" and hypoplastic mandible. The goal of surgical correction of MCC is to provide adequate healthy tissue coverage, as well as restore contour of the anterior neck. The primary treatment modality for midline cervical cleft is surgical. We describe a technique involving complete excision of the fibrous cord, and use of double z-plasty flap in order to create a tension-free closure and restore contour to the anterior neck.

METHODS

Using a database search method, children with the clinical diagnosis of midline cervical cleft treated between 2006 and 2016 were identified at a pediatric tertiary care center. Chart review was completed to assess for age at surgery, follow up, results, and complications.

RESULTS

12 patients were identified in the Lurie Children's Hospital (LCH) database. 8 patients underwent complete cord excision by the seniorauthor using the double z-plasty (DZ) technique for closure, with no recurrences. 4 patients underwent linear closure by another surgeon, had persistent contracture, and underwent revision using the DZ technique by the senior author, with no recurrence. Average age of surgery was 9.5 months. Most common post op complication was hypertrophic scar (3/12). Recurrence was only seen in the linear closure cases (4/12).

CONCLUSIONS

Midline Cervical Cleft is a rare entity with less than 200 cases in the literature. We believe the double z-plasty closure and complete excision of the fibrous cord results in reproducible restoration of neck contour and prevents cord recurrence, and should be considered the standard method for surgical excision of MCC.

Segmental aponeurectomy with Z-Plasty as a treatment option in Dupuytren's disease: A retrospective cohort study

BACKGROUND

Aponeurectomy remains the reference standard treatment for digit tethering by palmar fascial cords in Dupuytren's disease but is associated with a substantial complication rate. An alternative technique decreases metacarpophalangeal joint (MCPJ) flexion contracture by combining palmar segmental aponeurectomy with Z-plasty skin closure. The primary objective of this study was to assess range of motion of the operated ray after the procedure. The secondary objectives were to assess the complication rate and to determine the recurrence rate after at least 1 year.

HYPOTHESIS

Palmar segmental aponeurectomy with Z-plasty closure may provide the advantages of aponeurectomy while decreasing the surgical risk and recurrence rate.

MATERIAL AND METHODS

A retrospective study was conducted in 16 patients with predominant MCPJ flexion contracture due to a well-defined palmar fascial cord. Anaesthesia was loco-regional. The Z-plasty design involved a longitudinal incision along the palmar cord with an oblique incision at each end at a 60° angle to the longitudinal incision. The length of the aponeurectomy was about 1.5cm, to allow full MCPJ extension.

RESULTS

In all, the 16 patients-13 males and 3 females-had 17 segmental palmar aponeurectomy procedures with Z-plasty closure. Mean operative time was 18minutes. Before surgery, mean loss of extension was 47° at the MCP joint and 15° at the corresponding proximal interphalangeal joint (PIPJ). Immediately after surgery, a 97% improvement in MCPJ extension was noted, leaving a mean extension deficit of 1.25°. Mean follow-up was 18.9 months. No complications occurred. Two patients experienced a recurrence.

DISCUSSION

Segmental palmar aponeurectomy as described by Moermans in 1991 improves extension similarly to extensive aponeurectomy but has a lower complication rate. Z-plasty provides good exposure of the pedicles and takes advantage of the greater pliability of the skin on either side of the cord to lengthen the skin by 75%, thereby limiting the risk of the complications seen with needle aponeurotomy. Segmental palmar aponeurectomy with Z-plasty has a role in the management of Dupuytren's disease with flexion contracture predominantly involving the MCPJ.

Checkrein Deformity of the Great toe Managed by Midfoot Flexor Hallucis Longus Z-Plasty: A Case Report

Introduction:

Checkrein deformities are rare and involve entrapment or fixed tethering of the flexor hallucis longus (FHL) tendon.

Case Report:

We present the case of a 25-year-old male who presented with complaint of clawing of his great toe. A history of previous open reduction internal fixation for distal tibia fracture was described 3 years back. Exploration of FHL tendons was performed at the level of the midfoot. Correction was achieved after z-plasty of FHL tendon. This case highlights another late complication of distal tibial fracture which should be actively looked for in patients with this injury. We describe the ease of surgical correction through an operative field free of scar tissue as compared to classical method of operating near fracture site and releasing adhesions of muscle belly.

Conclusion:

We suggest that exploration at the midfoot should be the primary surgical intervention in similar cases of checkrein deformity.

Achilles Lengthening and Multiple Z-Plasty in Parallel for Correction of Toe Walking Associated With Burn Scar Equinus Contracture

The literature is sparse regarding treatment of burn scar equinus contracture, with focus primarily on staged procedures, serial casting, and gradual correction using external fixation in combination with soft-tissue procedures. This case study describes a single-stage ambulatory approach for late-stage correction of burn scar equinus contracture associated with toe walking. A case report is presented of an 11-year-old male with focus on procedure selection, surgical technique, and 12-month follow-up results. Surgery involved a single-stage approach with open Achilles lengthening, in addition to multiple skin Z-plasty in parallel with immediate protected weightbearing to correct toe walking. Inadequate release of contracture was noted intraoperatively after Achilles lengthening. Full correction was achieved after converting the longitudinal incision into multiple Z-plasty in parallel, with full heel purchase at 2 weeks postoperatively. The patient was completely healed with pain-free range of motion at 6 weeks postoperatively. At 12 months postoperatively, he continued to ambulate normally without overcorrection or recurrence of deformity. This case study describes a late-stage, minimally invasive, single-stage approach to correction of burn scar equinus contracture. The surgical principles and technique are described. Allowance of immediate weightbearing was possible because all other burn wounds were healed at late-stage presentation that avoided the need for gradual correction with external fixation or serial procedures.

Congenital midline cervical cleft: a case report

Background

Midline cervical cleft is a very rare congenital anomaly. According to a literature search, until 2014 only 205 cases were reported.

Case presentation

We present a classic case of congenital midline cervical cleft. This was a case of a 3-year-old Middle Eastern boy. The lesion was excised and the defect was closed via multiple Z-plasties.

Conclusions

Midline cervical cleft, although a rarity, when presented needs surgical treatment, which comprises surgical excision and closure that lessens the possibility of scar visibility and contracture.

Comparison between simple release and Z-plasty of retinaculum for de Quervain's disease: a retrospective study

We compared two surgical procedures for de Quervain's disease that was not responsive to conservative treatment. Group A (simple release) consisted of 38 patients and group B (Z-plasty of the retinaculum) included 36 patients. The visual analogue scale score and the Disabilities of the Arm, Shoulder and Hand Score improved significantly after surgery; there were no statistical differences in outcome between the two groups. In group A, one patient required reoperation, two had subluxations of extensor tendons and two had temporary loss of sensation in the area of the radial nerve. In group B, two patients had temporary loss of sensation. The mean time to resolution of pain at the operative site was significantly shorter in group B. Both simple release and Z-plasty were effective surgical methods. Z-plasty allowed earlier return to activities of daily living but there was no statistical difference between the two groups in incidence of complication. Level of evidence: IV.

Surgery for scar revision and reduction: from primary closure to flap surgery

Scars are the final result of the four processes that constitute cutaneous wound healing, namely, coagulation, inflammation, proliferation, and remodeling. Permanent scars are produced if the wounds reach the reticular dermis. The nature of these scars depends on the four wound healing processes. If the remodeling process is excessive, collagen degradation exceeds collagen synthesis and atrophic scars are produced. If the inflammation phase is prolonged and/or more potent for some reason, inflammatory/pathological scars such as keloids or hypertrophic scars can arise. If these pathological scars are located on joints or mobile regions, scar contractures can develop. When used with the appropriate timing and when selected on the basis of individual factors, surgical techniques can improve mature scars. This review paper focuses on the surgical techniques that are used to improve mature scars, burn scars, and scar contractures. Those methods include z-plasties, w-plasties, split-thickness skin grafting, full-thickness skin grafting, local flaps (including the square flap method and the propeller flap), and expanded flaps, distant flaps, regional flaps, and free flaps.

Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections

OBJECTIVE

Sternal wound infections after sternotomy are associated with high morbidity, high mortality, and prolonged hospital stay. The recurrence rate of sternal wound infections after single-stage closure is greater than expected. The aim of the study is to present our results of a consecutive series of Z-plasty for the treatment of recurrent sternal wound infections.

METHODS

Between March 2015 and March 2017, a total of 9 patients were referred to our clinic with a recurrent sternal wound infection due to sternotomy with or without osteomyelitis. All patients previously underwent one or more surgical procedures for sternal infection. Negative pressure wound therapy and several debridement methods were performed before reconstruction. Two triangular double-transposition fasciocutaneous flap techniques as Z-plasty under local anesthesia was performed for all of the patients.

RESULTS

The flaps survived completely without any tissue loss. There were no major postoperative complications. One patient had recurrent infection after the flap procedure and was treated with antibiotic therapy. At 6 months of follow-up, all of the patients were able to return to normal activities of daily living with a high patient satisfaction rate.

CONCLUSIONS

Local sternal wound reconstruction is an effective, rapid, and simple with Z-plasty associated with low recurrence risk. We believe that Z-plasty can be used for recurrent local sternal wound infections as an alternative treatment option for selected patients without mechanical dehiscence.

Prepuce sparing: Use of Z-plasty for treatment of phimosis and scarred foreskin

INTRODUCTION AND OBJECTIVES

The desire to preserve the prepuce is often based on cultural norms. Recently, the concept of "genital autonomy" has been invoked to delay circumcision (or any genital altering procedure) until the individual reaches maturity and can make his or her own decision. However, some uncircumcised boys develop one or more episodes of balanitis resulting in scarring of the prepuce and pathologic phimosis which is difficult to treat. Herein we report on the management of severe phimosis and preputial scarring using preputial Z-plasties.

MATERIALS AND METHODS

We reviewed the records of 28 patients, aged 3-12 years who underwent prepuce-sparing surgery within the previous 5 years with a minimum follow-up of 6 months. All patients were uncircumcised, with severe phimosis defined as a tight, pinpoint opening. All patients failed to respond to 6-10 weeks of betamethasone treatment. All parents requested preservation of as much of the foreskin as possible.

RESULTS

All patients healed satisfactorily, without infection, hematoma, or flap necrosis. One child developed mild scarring which responded to local steroid application. At follow-up evaluation, ranging from 6 to 24 months, the prepuce was fully retractable in all patients (Fig.).

CONCLUSIONS

Excision of the scarred preputial ring results in a circular suture line, which is in essence a straight line, curved and connected at each end, and this is likely to contract over time. The principle of Z-plasty can be exploited to elongate and interrupt the straight line, preventing contracture thus widening and sparing the prepuce.

Unilateral Cleft Lip Repair With a Simple Assymetric Z-plasty

Objective: The objective of this case report is to provide an example of the repair of a complete unilateral cleft lip using a modification of the classic Z-plasty. Methods: A Z-plasty for cleft lip is described that does not depend on measurements and formulas. The tissue available on the lateral lip "unit" determines the limb length of the Z: from cupid's bow to the highest point of "good" lip skin. This length is then transposed to the medial side, scribing an arc from both cupid's bows. Where the arcs intersect determines length and direction of the releasing incision. The angles are not predetermined as in a classic Z. The incisions are made "on block" through skin, muscle, and mucosa. Flap transposition uprights the isosceles triangle-shaped philtrum, aligning the cupid's bows. Results: All degrees of unilateral cleft lips have been successfully repaired using this technique. The operation is simple, rapid, and dependable. There is minimal bleeding, as there is no muscle dissection. On both medial and lateral sides, the muscle is transposed toward the free border, that is, downward. Achieving downward rotation of cupid's bows along with the philtrum dimple provides attractive fullness and pout to the lower part of the upper lip. Fullness and length are permanently maintained by the medially based flap under the nose. Conclusions: The Z-plasty is well suited for unilateral cleft lip repair. It is especially useful for wide, complete cases but is applicable to all types of unilateral cleft lips. It is a simple, fast, and stable repair.

Treatment of patella baja by a modified Z-plasty

PURPOSE

The purpose of this study was to evaluate the efficiency of a modified Z-plasty for patellar tendon lengthening for the treatment of patella baja. Rather than adapting only two tendon reins according to the conventional Z-plasty method, the modified Z-plasty provides four reins to enable multifold overlapping of the tendon tissue.

METHODS

Between 2010 and 2012, a modified Z-plasty procedure was performed in four patients suffering from patella baja. Physical examinations and standardized scoring instruments served as the evaluation measures.

RESULTS

The median preoperative CD ratio of 0.53 (range 0.43-0.62) was corrected to 1.03 (range 1-1.06) after a median follow-up of 34 months (range 23-41 months). The median preoperative flexion of 108° (range 80-135°) improved to 143° (range 110-145°) compared with the flexion of 145° (range 140-145°) of the unaffected knee. No patients showed any signs of extension lag. The median Lysholm score improved from 49 (range 22-80) to 91 (range 67-95), and the Tegner activity level improved from 2 (range 0-6) to 6 (range 2-6). The median VAS status for pain decreased from an average of 8.5 (range 4-10) to 1 (range 0-2). No complications were observed.

CONCLUSION

The modified Z-plasty procedure is a valuable technique for the treatment of patella baja, especially if allografts are not available. This procedure allowed for early mobilization and achieved excellent clinical results.

LEVEL OF EVIDENCE

IV.

A Comparison of Hand Pain and Hand Function after Z-plasty Reconstruction of the Transverse Carpal Ligament with Traditional Median Neurolysis in Carpal Tunnel Syndrome

BACKGROUND

Carpal tunnel syndrome is the most common focal mono-neuropathy. A study was designed to compare the effects of traditional open carpal tunnel release with median neurolysis and Z-plasty reconstruction of the transverse carpal ligament on post-operative hand pain and hand function in patients with idiopathic carpal tunnel syndrome.

METHODS

Fifty-two patients with idiopathic carpal tunnel syndrome entered the study. The patients were randomly assigned into two groups to undergo simple transverse carpal ligament release or division of the ligament with Z-lengthening reconstruction. Forty-five patients completed the study. Two patients of the simple open surgery group and 5 patients of the Z-plasty reconstruction group did not complete the follow up course. After the procedure, the patients were followed to assess post-operative pain and hand function during a 12-week period.

RESULTS

The scores of hand pain on the first day after surgery were not statistically different between the two groups (P=0.213). But the score of hand pain was significantly lower in the Z-plasty reconstruction group at week 1, week 3, and week 6 after surgery (P<0.001). However, at week 12, no patient complained of hand pain in both groups. Considering hand function, no patient had normal hand grip after the first week, but after three weeks, a significantly higher proportion of patients in the Z-plasty reconstruction group had reached near normal hand grip (76.1% vs. 29.1%;). However, at weeks 6 and 12, the differences were not statistically different between the two groups.

CONCLUSION

We observed significant reduction in hand pain, shorter duration of hand pain and shorter period of time to reach normal hand grip by Z-plasty reconstruction of the TCL.

Congenital midline cervical cleft: A retrospective case series of 8 children

OBJECTIVES

Congenital midline cervical cleft is a rare developmental abnormality of the ventral neck of unclear etiology. It consists of a midline skin defect. This study reports a case series of 8 patients with congenital midline cervical cleft.

METHODS

Retrospective review chart including all children referred with congenital midline cervical cleft over 5 years in tertiary center. The study was conducted to determine the presence of associated malformations, to specify the cleft pathology, to analyze the nature of associated cysts, and to discuss surgical procedure.

RESULTS

Eight patients ranged from 3 days to 5 years. Two had an associated cervical midline cyst, 3 had a significant micrognatia. Pathological observations were in favor of a branchial origin. There was no recurrence of cervical contraction after a mean follow-up of 20 months.

CONCLUSION

Congenital midline cervical cleft is a rare and generally isolated congenital malformation. It does not require either extensive assessment or specific genetic. Described associated cysts might be part of the cleft and not bronchogenic or thyroglossal cysts. Early surgical excision reduces cervical contracture, but linear or Z-plasty closure is still debated.

Management of Midline Facial Clefts

Median or midline facial clefts are rare anomalies of developmental origin, etiology of whose occurrence is still unknown precisely. The most basic presentation of midline facial clefts is in the form of a Median cleft lip which is defined as any congenital vertical cleft through the centre of the upper lip. First described by Bechard in 1823, it is the most common amongst all atypical clefts reported. The incidence is about 1:10,00,000 births. This may occur as a sporadic event or as a part of an inherited sequence of anomalies. It arises embryologically from incomplete fusion of the medial nasal prominences. The authors present a series of eight cases with varying degrees of midline facial clefts. This review article aims to give a broad idea on the various classifications used for further understanding of midline facial clefts and a brief idea about the various surgical management techniques used in the repair of these facial clefts.

Reconstruction of skin defects in the medial cheek using lateral cheek rotation flap combined with Z-plasties

BACKGROUND

Cervicofacial flaps are commonly used in the reconstruction of skin defects in regions such as the medial cheek and lower eyelid. However, their drawbacks include long flap incision, extensive undermining, and a high possibility of postoperative complications including distal flap necrosis and lower eyelid ectropion.

METHODS

Nine cases of reconstruction of skin defects in the medial cheek and adjacent areas were performed using a lateral cheek rotation flap in combination with Z-plasties between October 2009 and August 2014. In the surgery, the defect was trimmed into a downward-pointing triangle, with the flap incision line starting from the bottom edge of the defect and extending outward in the lateral orbital direction in an arc until before the sideburn. After the flap was undermined, double or quadruple Z-plasties were performed along the lateral orbital incision line to elongate the flap.

RESULTS

All flaps survived without the occurrence of complications such as hematoma, wound infection, distal flap necrosis, and lower eyelid ectropion. During the follow-up period, the flaps exhibited good color and texture. A natural looking cheek was restored without obvious scars.

CONCLUSIONS

A lateral cheek rotation flap in combination with Z-plasty is an optimal method for reconstruction of skin defects in the medial cheek and lower eyelid region. Compared to conventional cervicofacial flaps, the lateral cheek rotation flap was shown to have a variety of advantages, including a simpler operation, shorter flap incision, minimal undermining, and effective prevention of complications such as lower eyelid ectropion and distal flap necrosis.

A rare case of eccrine spiradenoma-treatment and management

A young male patient presented with multiple swellings on his chest and the nape of his neck. Physical examination revealed multiple small papulonodular swellings measuring 0.5 × 0.5 cm to 2 × 2 cm, that were soft without discharge with no surrounding skin changes or induration. Skin biopsy samples were diagnosed as benign adnexal neoplasm consistent with eccrine spiradenoma, trichoepithelioma, and cylindroma, i.e., Brooke-Spiegler syndrome. Having confirmed this to be a case of eccrine spiradenoma, surgical excision was performed and the raw area was covered with a split thickness skin graft taken from the right thigh and sutured over the raw area. The sternal lesion was circumferentially excised and the wound was primarily closed by Z-plasty. Surgical excision is considered the gold standard for the treatment of these cases, with low rates of recurrence. Around 50 such cases have been reported in the literature to date. Although eccrine spiradenomas are usually solitary and small, the findings in our case underscore the fact that a variety of presentations are possible. With strict clinical suspicion and histological criteria, the correct diagnosis can be achieved, especially when combined with pertinent clinical information and laboratory studies.

LEVEL OF EVIDENCE

Level V, therapeutic study.

Tongue-tie Repair: Z-Plasty Vs Simple Release

INTRODUCTION

Ankyloglossia is a congenital anomaly in which the lingual frenulum is unusually short and thick, thus decreasing tongue mobility. In the context of the newborn or young infant it is a subject of ongoing controversy within and between medical specialties. The controversy involves not only the definition but also the management of this anomaly. A tight lingual frenulum is considered a minor malformation by some investigators. Usual treatments for ankyloglossia include speech therapy, as well as simple frenulotomy and frenuloplasty. The aim of this study was to compare the latter two methods with respect to postoperative results and complications.

MATERIALS AND METHODS

A total of 50 patients referred for surgical care were randomly assigned into two groups: simple release (frenulotomy ) or Z-plasty (frenuloplasty), and underwent a pre-surgical assessment. After 3 months, patients were followed with a scheduled interview and questionnaire comparing the outcomes of the two methods. The data were analyzed using SPSS version 18.

RESULTS

Surgery had a significant effect on all variables measured in our study (P<0.05). Z-plasty had a greater effect on articulation, breast pain, tongue movement and parent satisfaction than simple release (P<0.05). Z-plasty and simple release had the same effect on breast feeding, latching, and sucking.

CONCLUSION

Z-plasty is the preferred surgical method to address tongue-tie due to a greater improvement in mother's breast pain, pronunciation and speech, tongue movement, and parental satisfaction.

Familial ainhum: a case report of multiple toe involvement in a father and son, staging of ainhum with insight into different types of constricting bands

Ainhum, also known as dactylolysis spontanea, is a painful constriction of the base of the fifth toe, frequently followed by spontaneous amputation a few years later. The disease is often symmetrical on both the feet, but, occasionally, other toes are also affected and rarely the distal phalanx of the fifth finger. Pseudoainhum is a similar condition that occurs as a secondary event resulting from certain hereditary and nonhereditary diseases that lead to annular constriction of digits. We hereby present a case of familial ainhum in father and son with multiple toes affected, autoamputation, and more involvement of fourth toe than the fifth toe, which is a very rare finding.

Combination of rhomboid flap and double Z-plasty technique for reconstruction of palmar and dorsal web space burn contractures

BACKGROUND

Web space contractures after a burn can cause severe impairments in hand function along with esthetic deformities. In this study we present our experience with the combined treatment technique consisted of rhomboid flap and double Z-plasty for palmar and dorsal web space contractures.

MATERIALS AND METHODS

Combined rhomboid flap and double Z-plasty was performed in eight patients with eleven web space contractures occurred after burn. The average follow-up was 10.9 months.

RESULTS

The average age of 8 patients was 16.3 years. The average duration of burn contractures was 6 years (range 1-13 years). The right third web of the patients was the most common contracted web space. In the postoperative period hematoma, infection, partial or total flap loss was not observed in any patient. Web and hand function and esthetic appearance of web spaces were satisfactory in the late postoperative period.

CONCLUSION

Rhomboid flap combined with a double Z-plasty technique was an effective choice for the treatment of palmar and dorsal web space contracture after burn.

Ainhum: A Spot Diagnosis

Ainhum is an acquired progressive condition presenting with a constriction ring around the fifth toe. Classically, it was reported in people of African origin and has been very rarely reported in India. Ainhum when diagnosed and treated early can be prevented from progressing to mutilating deformities. It needs to be differentiated from pseudo ainhum, which may have a precipitating factor, and careful history may reveal a preventable cause. We report a case of ainhum with involvement of the left fifth toe and early involvement of other toes.

Correction of Unilateral Nostril Hypoplasia with Z-Plasty in a Child

Unilateral nostril hypoplasia is an extremely rare congenital malformation of unknown etiology, and only a few cases have been reported in literature. Owing to variability and complexity of the deformity, surgical correction of unilateral nostril hypoplasia represents one of the most significant reconstructive challenges to reconstructive plastic surgeons. We report a 7-year-old Vietnamese child with nasal and periocular deformity resembling a craniofacial cleft. Grossly, the right nostril was patent but with alar rim deformity, and the left nostril was not readily identifiable. A dystopic medial canthus was present on the left side as well. Closer inspection and palpation of the left side of nose revealed a patency through the soft tissue and underlying bony structure, Thus, a new alar rim were reconstructed with an irregularly shaped Z-plasty to create patency on the involved side. Simulatneously, a second Z-plasty was performed to address the medial canthal deformity. Postoperative appearance and function was sastisfactory at one-year follow up visit. In the treatment of patients with nostril hypoplasia, a careful preoperative physical examination is a prerequisite, and Z-plasty can be a valuable option for surgical correction.

Dynamic positional deformity of the hallux

The present study reports a case with concomitant tethering of the flexor tendon and extensor tendon of the hallux after closed tibiofibular shaft fractures. We have obtained good clinical results using tenotomy of the flexor hallucis longus tendon and Z-plasty lengthening of the extensor hallucis longus tendon. Because few studies have described the clinical results and operative methods for this type of combined deformity, we report a case with dynamic positional deformity of the hallux.

Surgical scar revision: an overview

Scar formation is an inevitable consequence of wound healing from either a traumatic or a surgical intervention. The aesthetic appearance of a scar is the most important criteria to judge the surgical outcome. An understanding of the anatomy and wound healing along with experience, meticulous planning and technique can reduce complications and improve the surgical outcome. Scar revision does not erase a scar but helps to make it less noticeable and more acceptable. Both surgical and non-surgical techniques, used either alone or in combination can be used for revising a scar. In planning a scar revision surgeon should decide on when to act and the type of technique to use for scar revision to get an aesthetically pleasing outcome. This review article provides overview of methods applied for facial scar revision. This predominantly covers surgical methods.