DE-EPITHEUALIZATION AND OVER-FLAPPING
MEHROTRA
DE-EPITHELIALIZATION AND OVER-FLAPPING IN PLASTIC SURGERY 0. N. MEHROTRA Plastic Surgical Unit, Middlemore Hospital,
A uckland. Contour defects resulting from trauma, from the excision of a neoplasm,or present at birth, may be restoredine number of ways, and the material used may be autogenous,homogenous,heterogenous, or synthetic in nature. The use 01 Silastic implants is currently fashionable, but despite the manufacturer's clalms, there is no foreign material which the body will accept permanently as Its own. implants are easy to procureand to shape, and their use can sometimes simplify a surgical procedure, but there is no doubt that where autogenous material 15 available, it will almost always give the best and most permanent result. This paper illustrates the Versatility Of simple de-epltheliallzationand over-flapping procedures in restoring contour defects, and is also a plea for the use of living tissue where it is readily available.
PATIENTS CIinicaI Records ( 7 )Trauma
CASE 1.- A 47-year-old man suffered an extensive Wn-shot wound to his face (Figure i , left). After resuscitation a tracheostomy was performed, and the shattered bony fragments of the mandible and maxilla were held simply b y wire ligatures. Temporary healing was achieved by skin grafting (Figure 1 , right), and a definitive reconstruction carried out later using a deltopectoral flap. Lining was provided by turning in the free graft applied at the original operation, but it was apparent that one thicknessof thedeltopectoral flap wouldnot be sufficient to restore thecontour defect, so thedistal part was de-epithelialized and cut at cheek level and the rest of the flap advanced over it in the process known as "over-flapping'' (Figure 2, left).
Bone grafting was carried out at the same time, and a very pleasing final result was achieved (Figure 2. right). CASE2:- A 20-year-old man was involved in a motor vehicle accident, sustaining a very extensive compound injury to his right lower leg, with considerable loss of soft tissue and bone (Figure 3, upper). Repair was effected with a groin flap, the margin of which was deepithelialized for Some four centimetres and used to fill the defect (Figure3, tower), thereby obviating the need for bone grafting. Afterthinning the flap the result was most satisfactory. (2) Neoplasms
CASE3.- This patient was a 60-year-old man who had been treated by radiotherapy for a squamous cell carcinoma of his maxillarv antrum H e had been left with anecrotic area and an oionasai cutaneous fistula through which food could escape out on to hischeek. causing him agreat deal of embarrassment. Repair was done using a de-epithelialized island flap to provide lining as well as cover, and the fistula wasthus ableto beclosed with a most gratifying result. (3) Congenital deformities CASE 4.- This patient has facial hemiatrophy (Figure 4, left). Here a free dermis graft was used to restorethecontourdefect. The immediate result was pleasing (Figure 4. right). but Reprints. 0 . N. Mehrotra, M.s.. F R A.c.s.. Visiting Plastic Surgeon. Plastic Surgery Unit. Middlemore Hospital. Auckland. New Zealand.
AUST N.Z. J. SURG.VOL 48 - No 6, DECEMBER. 1978
resorption occurred, and the process had t o be repeated on more than one occasion. Had a de-epithelialized flaps, as used i n C a s e l . orasused byHarashina,etalii.(1977) beenappliedin the first instance, a more permanent result would have been achieved, and it would also have compensated for the skeletal hypoplasia which is sometimes associated with this condition. DISCUSSION
Neuber (1893) was the first to attempt free fat transplants to restore contour defects, but it was Lexer (1925) who applied them widely to establish nOrmal COntOUr in facial hemiatrophy and underdevelopment of the breasts. The results were, however, disappointing, because of complete resorption. Peer (1956) used dermis and fat, after removing the epithelium, for soft tissuedeficiencies Of the face, breast and Other places. and when more bulk was required, more than one operation was performed, Watson (1959) used dermis-fat grafts in mammary hypoplasia and, although about 15% shrinkage Of the graft occurred, the results Were considered to be satisfactory after two years, This method did not gain popularity, however, and was replaced by the use of Silastic 'implants. of de-epithelialization are permanent The Only when a vascu~arconnectioncan beestbalished between the recipient area and the flaD. When the flapis used as 'a free graft, and pa;ticularly in mammary hypoplasia* the resultsare often disappointing. This fact led to the search for new methods, and the easily available synthetic materials became very popular. Antia and Buch (1971) used miCroVaSCular free flap transfers to restore a defect left after excision of a hemimandible and maxilla affected by ameloblastoma. They took the inferior epigastric
653
DE-EPITHEUALIZATION AND OVER-FLAPPING
MEHROTRA
FIGURE 1: Case 1 (left) gunshot injury to the face; (right) temporary healing by skin grafting. Repair
by a
dellopectoral flap.
FIGURE2 Case 1 (left) de-eptthelialized and over-flapped, (right) final result 6.54
AUST N.Z J SURG.VOL 48
- No
6, DECEMBER, 1978
DE-EPITHEUALIZATION AND OVER-FLAPPING
MEHROTRA
artery and a four millimetre disc of femoral artery and saphenous vein and anastomosed it to the external carotid artery and internal jugular vein. Fujino et alii (1975) used a free deltopectoral flap for the repair of facial hemi-atrophy, and more recently Harashina et alii (1977) used a two-staged groin flap in a similar condition. De-epithelialization of a flap, however, does not compromise its vascularity; on the contrary, it enhances it, because the subpapillary plexus has a rich vascular anastomosis and picks u p the blood supply quickly. A one-stage procedure is therefore quite safe. Manchester’s (1971) method of lip repair is another application, where de-epithelialization of the lateral part of the vermilion is done t o produce a nice central tubercle a n d a p o u t i n g lip. Durham-Smith (1973) used the same principle for hypospadias repair, with only one fistula in his series of 51 cases. Hynes’s (1961) method of shaving and skin grafting unstable areas of the leg following injuries is also a useful method in selected cases. FIGURE3 Case 2 (upper) leg injury with loss of soft tissue and bone, (lower) de-epithelializalion completed andover-flapping done
In recent years there has been a tremendous swing towards the use of synthetic materials, and
FIGURE4 Case 4 (left) facial hemiatrophy (right) fatdermis graft with good Immediate result Resorption started after a few months
AUST N.2 J. SURG, VOL 48 - No 6, DECEMBER. 1978
655
MEHROTRA
DE-EPITHEUALIZATION AND OVER-FLAPPING
one sees beautiful short-term results, but in the long term they are often disappointing and in somecases quite disastrous. Conventional and microvascular free flaps, combined with de-epithelialization and over-flapping, are able to solve the problems of most contour defects, i n c l u d i n g mammary hyoplasia, with permanent and predictable results, and it is the opinion of the author that synthetic materials should be considered only after every possibility of using autogenous material has been exhausted. De-epithelialization and over-flapping constitute a simple procedure which can be done by sandpapering, with a dermatone, ascalpel, oreven askin grating knife, and carried out as a normal plastic surgical procedure. There was some initial reluctance to deepithelialization for fear of cyst formation and infection, and this impeded its early wider application, but results have now dispelled this fear. Thompson (1960),while discussing the fate of buried epithelial remnants, quoted a figure of 3.4%
of patients who presented clinically with epidermal cysts required operative procedures. In this small series there has been n o evidence of cyst formation. The possibility is recognized, but the incidence of cyst formation requiring surgery is negligible. Epithelial remnants do form microscopic cysts, but they are eventually replaced by scar tissue.
REFERENCES ANTIA. M. H. and BUCH, V. I. (1971), Brit. plast. Surg., 24: 15. FUJINO, T. TANINO, R and SUGIMOTO. C.(1975),Plast. reconsf. Surg. 55: 428. T.. NAGAJIMA, T. and YOSHIMURA. Y. (1977), Brit. J. HARASHINA, plast. Surg., 30, 1: 14-16. HYNES. W. (1961) Brit. J. plast. Surg., 9: 47. LEXER, MANCHESTER, W. M. (1971), “A Method of Primary Double Cleft Lip Repair”. Transactions of the Fifth international Confederation of PlasticandReconstructive Surgery, Melbourne 1971: 193. NEUBER (1893). Fettransplantation. Chir. Kingr. Verhand. Dtsch. Gesellsch. Chir. 22: 66. PEER, A. (1956), Plast. reconstructive Surg.. 18. 233. SMITH, E. D.. (1973), Brit. J. plast. Surg., 262: 106. THOMPSON, N. (1960), Brit. J. Plasf. Surg., 13: 219 J. (1959) Brit. J. plast. Surg.. 12: 263. WATSON,
LASER SURGERY FOR MALIGNANT MELANOMA AND SUPERFICIAL MALIGNANCIES W. H. MCCARTHY’, H. M. S H A WAND ~ p. H. JONES3 Department of Surgery, University of Sydney, Sydney Hospital This study describes 18 months’ experience with the C02 laser In the treatment of malignant melanoma and other superficial malignancies. In 110 patients, a general assessment was made of the advantages commoniy claimed for the laser. In addition, a comparison between laser and scalpel surgery was made by means of a Small retrospective study. Results from 39 patients undergoing wide excision and graft for primary malignant melanoma in association with axlllary lymph node dssection indicated that the laser offered no specific advantages over the scalpel for this particular type of operation. The laser was shown to have specific advantages in the treatment of extensive superficial malignancy, in locally recurrent tumours, and in malignancy of soft tissues. In these situations it did minimize blood loss and achieve satisfactory extirpation of the lesion.
THE word “laser” is an acronym for Light Amplification by the Stimulated Emission of Radiation. Conventional light is caused by the spontaneous emission from a light source radiated I
Associate Professor of Surgery, University of Sydney.
3
Laser Technician. Sydney Hospital.
Research Assistant. Melanoma Clinic. Sydney Hospital.
Reprints Associate Professor W H McCarthy. Department of Surgery, The Universityof Sydney,SydneyHospttal.MacquarieSt,Sydney,N S W 000
656
in all directions. The laser functions by focusing emitted light into a coherent beam, i.e., a parallel beam of light of uniform wavelength. This laser beam can then be focused by aseries of mirrorsand a lens on to a small areawhere it can produce power densities of high magnitude. A large number of different wavelengths of light can be used to form a laser beam. The laser -has proved useful in
commun’cation systems, weaponry, processes, and entertainment. AUST
N.Z. J. SURG,VOL 48
- No
industrial
6. DECEMBER 1978
MEHROTRA
DE-EPITHELIALIZATION AND OVER-FLAPPING IN PLASTIC SURGERY 0. N. MEHROTRA Plastic Surgical Unit, Middlemore Hospital,
A uckland. Contour defects resulting from trauma, from the excision of a neoplasm,or present at birth, may be restoredine number of ways, and the material used may be autogenous,homogenous,heterogenous, or synthetic in nature. The use 01 Silastic implants is currently fashionable, but despite the manufacturer's clalms, there is no foreign material which the body will accept permanently as Its own. implants are easy to procureand to shape, and their use can sometimes simplify a surgical procedure, but there is no doubt that where autogenous material 15 available, it will almost always give the best and most permanent result. This paper illustrates the Versatility Of simple de-epltheliallzationand over-flapping procedures in restoring contour defects, and is also a plea for the use of living tissue where it is readily available.
PATIENTS CIinicaI Records ( 7 )Trauma
CASE 1.- A 47-year-old man suffered an extensive Wn-shot wound to his face (Figure i , left). After resuscitation a tracheostomy was performed, and the shattered bony fragments of the mandible and maxilla were held simply b y wire ligatures. Temporary healing was achieved by skin grafting (Figure 1 , right), and a definitive reconstruction carried out later using a deltopectoral flap. Lining was provided by turning in the free graft applied at the original operation, but it was apparent that one thicknessof thedeltopectoral flap wouldnot be sufficient to restore thecontour defect, so thedistal part was de-epithelialized and cut at cheek level and the rest of the flap advanced over it in the process known as "over-flapping'' (Figure 2, left).
Bone grafting was carried out at the same time, and a very pleasing final result was achieved (Figure 2. right). CASE2:- A 20-year-old man was involved in a motor vehicle accident, sustaining a very extensive compound injury to his right lower leg, with considerable loss of soft tissue and bone (Figure 3, upper). Repair was effected with a groin flap, the margin of which was deepithelialized for Some four centimetres and used to fill the defect (Figure3, tower), thereby obviating the need for bone grafting. Afterthinning the flap the result was most satisfactory. (2) Neoplasms
CASE3.- This patient was a 60-year-old man who had been treated by radiotherapy for a squamous cell carcinoma of his maxillarv antrum H e had been left with anecrotic area and an oionasai cutaneous fistula through which food could escape out on to hischeek. causing him agreat deal of embarrassment. Repair was done using a de-epithelialized island flap to provide lining as well as cover, and the fistula wasthus ableto beclosed with a most gratifying result. (3) Congenital deformities CASE 4.- This patient has facial hemiatrophy (Figure 4, left). Here a free dermis graft was used to restorethecontourdefect. The immediate result was pleasing (Figure 4. right). but Reprints. 0 . N. Mehrotra, M.s.. F R A.c.s.. Visiting Plastic Surgeon. Plastic Surgery Unit. Middlemore Hospital. Auckland. New Zealand.
AUST N.Z. J. SURG.VOL 48 - No 6, DECEMBER. 1978
resorption occurred, and the process had t o be repeated on more than one occasion. Had a de-epithelialized flaps, as used i n C a s e l . orasused byHarashina,etalii.(1977) beenappliedin the first instance, a more permanent result would have been achieved, and it would also have compensated for the skeletal hypoplasia which is sometimes associated with this condition. DISCUSSION
Neuber (1893) was the first to attempt free fat transplants to restore contour defects, but it was Lexer (1925) who applied them widely to establish nOrmal COntOUr in facial hemiatrophy and underdevelopment of the breasts. The results were, however, disappointing, because of complete resorption. Peer (1956) used dermis and fat, after removing the epithelium, for soft tissuedeficiencies Of the face, breast and Other places. and when more bulk was required, more than one operation was performed, Watson (1959) used dermis-fat grafts in mammary hypoplasia and, although about 15% shrinkage Of the graft occurred, the results Were considered to be satisfactory after two years, This method did not gain popularity, however, and was replaced by the use of Silastic 'implants. of de-epithelialization are permanent The Only when a vascu~arconnectioncan beestbalished between the recipient area and the flaD. When the flapis used as 'a free graft, and pa;ticularly in mammary hypoplasia* the resultsare often disappointing. This fact led to the search for new methods, and the easily available synthetic materials became very popular. Antia and Buch (1971) used miCroVaSCular free flap transfers to restore a defect left after excision of a hemimandible and maxilla affected by ameloblastoma. They took the inferior epigastric
653
DE-EPITHEUALIZATION AND OVER-FLAPPING
MEHROTRA
FIGURE 1: Case 1 (left) gunshot injury to the face; (right) temporary healing by skin grafting. Repair
by a
dellopectoral flap.
FIGURE2 Case 1 (left) de-eptthelialized and over-flapped, (right) final result 6.54
AUST N.Z J SURG.VOL 48
- No
6, DECEMBER, 1978
DE-EPITHEUALIZATION AND OVER-FLAPPING
MEHROTRA
artery and a four millimetre disc of femoral artery and saphenous vein and anastomosed it to the external carotid artery and internal jugular vein. Fujino et alii (1975) used a free deltopectoral flap for the repair of facial hemi-atrophy, and more recently Harashina et alii (1977) used a two-staged groin flap in a similar condition. De-epithelialization of a flap, however, does not compromise its vascularity; on the contrary, it enhances it, because the subpapillary plexus has a rich vascular anastomosis and picks u p the blood supply quickly. A one-stage procedure is therefore quite safe. Manchester’s (1971) method of lip repair is another application, where de-epithelialization of the lateral part of the vermilion is done t o produce a nice central tubercle a n d a p o u t i n g lip. Durham-Smith (1973) used the same principle for hypospadias repair, with only one fistula in his series of 51 cases. Hynes’s (1961) method of shaving and skin grafting unstable areas of the leg following injuries is also a useful method in selected cases. FIGURE3 Case 2 (upper) leg injury with loss of soft tissue and bone, (lower) de-epithelializalion completed andover-flapping done
In recent years there has been a tremendous swing towards the use of synthetic materials, and
FIGURE4 Case 4 (left) facial hemiatrophy (right) fatdermis graft with good Immediate result Resorption started after a few months
AUST N.2 J. SURG, VOL 48 - No 6, DECEMBER. 1978
655
MEHROTRA
DE-EPITHEUALIZATION AND OVER-FLAPPING
one sees beautiful short-term results, but in the long term they are often disappointing and in somecases quite disastrous. Conventional and microvascular free flaps, combined with de-epithelialization and over-flapping, are able to solve the problems of most contour defects, i n c l u d i n g mammary hyoplasia, with permanent and predictable results, and it is the opinion of the author that synthetic materials should be considered only after every possibility of using autogenous material has been exhausted. De-epithelialization and over-flapping constitute a simple procedure which can be done by sandpapering, with a dermatone, ascalpel, oreven askin grating knife, and carried out as a normal plastic surgical procedure. There was some initial reluctance to deepithelialization for fear of cyst formation and infection, and this impeded its early wider application, but results have now dispelled this fear. Thompson (1960),while discussing the fate of buried epithelial remnants, quoted a figure of 3.4%
of patients who presented clinically with epidermal cysts required operative procedures. In this small series there has been n o evidence of cyst formation. The possibility is recognized, but the incidence of cyst formation requiring surgery is negligible. Epithelial remnants do form microscopic cysts, but they are eventually replaced by scar tissue.
REFERENCES ANTIA. M. H. and BUCH, V. I. (1971), Brit. plast. Surg., 24: 15. FUJINO, T. TANINO, R and SUGIMOTO. C.(1975),Plast. reconsf. Surg. 55: 428. T.. NAGAJIMA, T. and YOSHIMURA. Y. (1977), Brit. J. HARASHINA, plast. Surg., 30, 1: 14-16. HYNES. W. (1961) Brit. J. plast. Surg., 9: 47. LEXER, MANCHESTER, W. M. (1971), “A Method of Primary Double Cleft Lip Repair”. Transactions of the Fifth international Confederation of PlasticandReconstructive Surgery, Melbourne 1971: 193. NEUBER (1893). Fettransplantation. Chir. Kingr. Verhand. Dtsch. Gesellsch. Chir. 22: 66. PEER, A. (1956), Plast. reconstructive Surg.. 18. 233. SMITH, E. D.. (1973), Brit. J. plast. Surg., 262: 106. THOMPSON, N. (1960), Brit. J. Plasf. Surg., 13: 219 J. (1959) Brit. J. plast. Surg.. 12: 263. WATSON,
LASER SURGERY FOR MALIGNANT MELANOMA AND SUPERFICIAL MALIGNANCIES W. H. MCCARTHY’, H. M. S H A WAND ~ p. H. JONES3 Department of Surgery, University of Sydney, Sydney Hospital This study describes 18 months’ experience with the C02 laser In the treatment of malignant melanoma and other superficial malignancies. In 110 patients, a general assessment was made of the advantages commoniy claimed for the laser. In addition, a comparison between laser and scalpel surgery was made by means of a Small retrospective study. Results from 39 patients undergoing wide excision and graft for primary malignant melanoma in association with axlllary lymph node dssection indicated that the laser offered no specific advantages over the scalpel for this particular type of operation. The laser was shown to have specific advantages in the treatment of extensive superficial malignancy, in locally recurrent tumours, and in malignancy of soft tissues. In these situations it did minimize blood loss and achieve satisfactory extirpation of the lesion.
THE word “laser” is an acronym for Light Amplification by the Stimulated Emission of Radiation. Conventional light is caused by the spontaneous emission from a light source radiated I
Associate Professor of Surgery, University of Sydney.
3
Laser Technician. Sydney Hospital.
Research Assistant. Melanoma Clinic. Sydney Hospital.
Reprints Associate Professor W H McCarthy. Department of Surgery, The Universityof Sydney,SydneyHospttal.MacquarieSt,Sydney,N S W 000
656
in all directions. The laser functions by focusing emitted light into a coherent beam, i.e., a parallel beam of light of uniform wavelength. This laser beam can then be focused by aseries of mirrorsand a lens on to a small areawhere it can produce power densities of high magnitude. A large number of different wavelengths of light can be used to form a laser beam. The laser -has proved useful in
commun’cation systems, weaponry, processes, and entertainment. AUST
N.Z. J. SURG,VOL 48
- No
industrial
6. DECEMBER 1978
