A step-by-step guide to performing a laterally-based bilobed transposition flap for nasal tip reconstruction.
Specialty: Plastic Surgery
Excision of Facial Venous Malformation
Introduction:
Facial venous malformations are challenging vascular anomalies that can significantly impact a patient’s quality of life. These malformations, characterized by abnormal clusters of dilated veins in the facial region, can cause significant cosmetic deformities, bleeding, and functional impairments. Surgical excision of facial venous malformations is a treatment option, aiming to address both the concerns and functional limitations associated with these vascular anomalies.
Case presentation:
The affected area on the lateral aspect of the upper eyelid margin was treated with a YAG laser set at 20 watts and one-second exposure time. This was followed by excision of a 1 x 2 cm segment of the affected skin above the eyelid margin. Using electrocautery, the skin, subcutaneous tissue, and venous malformation were dissected, avoiding branches of the facial nerve to the orbicularis oculi muscle. The incision was carried around the obvious margins of the malformation down to the temporalis muscle fascia. The dissection was performed underneath the lesion until it was completely resected. After excision of a portion of the eyebrow involved in the malformation, the deeper parts of the upper eyelid and orbicularis muscle affected by the venous malformation were removed. The deep portion of the dissection was not very vascular and was controlled with the bipolar and monopolar cautery. To achieve primary closure, we carefully undermined the forehead and facial skin. The lower facial skin flap was elevated and advanced, and primary closure was achieved with Vicryl sutures. Closure of the eyelid skin to the lateral forehead skin followed with chromic and Vicryl sutures to alleviate tension. Although the larger vascular lesion was excised from the skin and subcutaneous tissue, residual malformation remained around the upper eyelid and lateral orbital rim. This was dissected under the skin to remove the vessels and preserve the eyelid skin. Post-procedure, Mastisol and Steri-Strips were applied to the suture line to relieve tension and help wound healing. The estimated blood loss was less than 30 mL. The patient had no complications and did well.
Conclusion:
In this case, the surgical intervention effectively removed most of the facial venous malformation. Despite some residual malformation, the procedure yielded satisfactory outcomes with no postoperative complications. The residual malformation in the upper eyelid can be controlled with a YAG laser and/or sclerotherapy.
External Dacryocystorhinostomy
This video demonstrates an external dacryocystorhinostomy surgery with insertion of a nasolacrimal duct stent in a patient with a history of dacryocystitis of rare fungal etiology.
Direct Brow Lift
The procedure in this video demonstrates a direct brow lift.
sural distal
sural distal
Midline Cervical Cleft Excision of Fibrous Cord – Z Plasty Closure
Z-plasty allows broken-line closure, reorientation of the defect in the horizontal plane with re-creation of a cervicomental angle, and most importantly, a lengthening of the anterior neck skin that aids in preventing recurrent contracture. We present our experience managing a congenital cervical midline cleft in a 3-month-old patient and describe a simple technique for planning the ideal Z-plasty closure. No simple description for planning the ideal closure for this defect could be found in the otolaryngology literature.
Punctal Dilation and Mini-Monoka Stent Insertion
This video demonstrates punctal dilation and insertion of a Mini-Monoka stent for treatment of epiphora due to punctal/canalicular stenosis.
Lacrimal Probing and Irrigation
This video demonstrates lacrimal probing and irrigation to investigate the anatomy, patency, and functional status of the lacrimal drainage system.
Rectovaginal Fistula Repair with a Vascularized Gracilis Muscle Interposition Flap
The surgical management of rectovaginal fistulas remains difficult, as they tend to be recurrent and vary widely in location and complexity. We present a case of a 63-year-old woman with a low-lying rectovaginal fistula who initially underwent chemoradiation and a Low Anterior Resection for a low-lying rectal cancer. Her course was uneventful until two years post-operatively, at which time her anastomotic staple line became stenotic with associated bleeding. This was initially addressed by Gastroenterology who executed a dilation and achieved hemostasis with Argon Plasma Coagulation. This remedied the stenosis, however, it was complicated by the formation of a rectovaginal fistula. Due to the low-lying location and its presence in an irradiated field, a transvaginal approach with an interposed gracilis flap was elected for repair.
A Pediatric Case of Levator Palpebrae Resection
In this video, we present a case of levator palpebrae resection in an 8-year-old patient with right eye ptosis.
In the pre-op photo, significant ptosis of the right eye can be appreciated. An incision was planned along the lid crease. 0.1 ml of 1: 100,000 epinephrine was injected. An incision was made by electro-cautery along the lid through the skin and orbicularis. Westcott scissors were used to further dissect horizontally. The septum was identified and opened. The preaponeurotic fat was identified and lifted, and the levator aponeurosis was identified. The levator was then tagged with two 6.0 Vicryle sutures, and isolated from surrounding tissues. Next, three6-0 Mersilene sutures were run from the upper tarsus to the levator. They are tightened with releasable notes. The lid elevation and contour were evaluated and adjustments were made until contour and height were equal and appropriate. The temporary surgical knots were transitioned into permanent surgical knots. Approximately 14 mm of excess levator was then excised. Next, three lid crease formation sutures were placed using 6-0 Vicryl. These were attached to the subcu-skin and levator to recreate the upper eyelid crease. Skin closure was performed with 6-0 fast-absorbing gut sutures. In this one-week post-op photo, the ptosis of his right eye was improved.
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