The anterolateral thigh flap (ALT) is an extremely versatile flap.  The lateral thigh can be utilized to bring an island  of tissue that is approximately 8cm X 24cm.  This amount of tissue removal can be closed with one incision.  Depending on the size of the area to be covered by the flap it may be necessary to harvest more tissue from the thigh.  If this is the case a skin graft will be utilized to close the resulting defect on the thigh.  I personally have used ALT flaps up to 35/25cm to cover large wounds of the chest and back.  Normally I utilize the ALT flap for coverage of the arm and leg.  It is very useful for the foot.  There are multiple ways to reestablish the blood supply to the transferred tissue but usually the posterior tibial blood vessels are used.  Microsurgery is used to reestablish blood flow to the tissues.  This is normally done by a plastic surgeon who has had additional training in microsurgery.  Typically these procedure are performed in microsurgery units or facilities where microvascular surgery is performed on a routine basis.  I typically perform, ALT flap, Latissimus flaps, gracilis flaps, DIEP flaps, and freestyle free flaps depending on the needs of the patient after Sarcoma tumor removal, trauma, or infection.  One of the additional points regarding ALT flaps is that they can be easily modified after surgery.  Through thinning of the fat and advancement of the flap a very thin pliable flap can be created which can be then almost indistinguishable in clothing from normal tissue.  Obviously externally there is a scar around the transferred tissue.  I believe this is an ideal flap for multiple reconstructive challenges.

Rhinoplasty ultimately changes the structure of the nose.  Anatomy is the key to understanding and performing rhinoplasty.The skin, nasal bones, upper and lower lateral cartilages externally and the septum internally are the key components in the framework of the nose.  Manipulating these structures will provide significant changes.  Whether it is done with an open or closed rhinoplasty techniques doesn't  matter. Many patients I see initially have septal issues.  The septum has three primary components.  The septal catilage, perpenicular plate of the ethmoid, and the vomer.  There can be a number of reasons for septal problems which nclude but are not limited to nonspecific deviation, deviation to trauma with or without fracture of the boney or cartilaginous septum.  Correction of these deformities can be done using open or closed rhioplasty techniques.  Once access has been gained to the septume and mucoperichondrium has been elevated the defect is evaluated.  The deviation is usually corrected through removal of the septal cartilage and bone.  A certain amount of cartilage is maintained to provide support in the form of an L - Strut.  Cartilage can then be used to provide more structural support in the form of spreader grafts or a columellar strut.  At this point the reconstruction of the septum is relatively complete.  I will contune to blog about nose surgery in the future.

The DIEP flap is an outstanding flap and ideal for large soft issue defects.  It has long been praised for the ability of this flap to provide a natural appearing breast reconstruction.  In addition to its utility in breast reconstruction this tissue flap is useful in a variety of other situations like arm and leg reconstruction after tumor removal like sarcoma.  In fact recently we have used the DIEP flap to care for patients with different sarcoma like angiosarcoma and fibromyoid sarcoma.  These patients have benefited from the quality and amount of skin and fat that can be transferred for their  arm and leg reconstruction just like the DIEP flap when it is used for breast reconstruction.  After multiple types of cancer surgeries the DIEP flap can be used.  Also it is very modifiable after the initial surgery has been performed.  Unlike a muscle flap and skin graft which has been traditionally performed for a number of years the DIEP flap is easily contoured through a combination of techniques involving liposuction of the fat and resection of the excess tissues.  Removal of the fat of the flap in the vertical dimension and the flap can be then stretched as well to flatten it even more.  This makes it ideal for the upper and lower extremity.  Of note this does remove the excess abdominal tissue that would normally be discarded in a tummy tuck procedure.  This procedure can be performed in a number of patients of different heights and weights.  If you are in need of reconstruction of the breast, large are or leg wounds the DIEP flap is a ideal source of healthy tissue.

This is a helpful article on many levels with respect to breast reconstruction.  It discusses the standard methods of your own tissue like the DIEP flap, breast implants, and the combinations of the two as well as future posibilities.  Always keep in mind that until you are seen and examined you should learn as much as possible to engage in a discussion with your breast surgeon and plastic surgeon.

http://www.webmd.com/breast-cancer/news/20080917/new-options-for-breast-reconstruction

This can be used in cases of osteosarcoma, rotationplasty involves a partial amputation of the leg above the knee. The lower leg and foot are rotated 180 degrees, the length is adjusted, and the tibia is then joined to the proximal femur using plates and screws. The foot is positioned where the knee used to be, with the heel portion in front and the toes pointing back. The ankle now functions in place of the knee joint. The primary reason for rotationplasty is to enhance the person's mobility as a prosthesis user. Placing the ankle joint in the position of the knee creates a functional, natural knee, and the toes provide important sensory feedback to the brain.

The appearance of the limb following rotationplasty is very unusual and is a concern for many people from both a cosmetic and a psychological standpoint. Patients and their families who are considering rotationplasty should talk with other people who have had the procedure and are now prosthesis users. For many, the functional advantages quickly outweigh their concerns about appearance. Children and young adults have a lifetime in front of them, and the increased mobility and freedom that may follow rotationplasty can be a significant improvement over the use of a traditional above-knee prosthesis.
 

I am becoming more and more concerned with people being told they are not candidates for the DIEP Flap because of previous abdominal surgery.  These surgeries don't necessarily eliminate you from having a DIEP Flap.  Essentially it depends on your previous surgeries.  If they were done in the middle of your abdomen then it should be relatively straight forward to identify your anatomy and perform the operation.  The typical c-section scar can be fine as well.  It has been my practice sine February 14, 2004 when I ordered the first perforator protocol Cat Scan (CT) of the abdomen at Froedtert&Medcial College of Wisconsin.  I just reviewed the images before writing this blog.  It has been a huge advantage to many of our patients with a history of prior abdominal surgery or who may have a pannus.  I have had many consultation where the patients have seen several surgeons prior to me because they were told that because of their abdominal scar that they would not be candidates.  We look at the blood vessel anatomy to identify to the best of our ability whether or not you can be a candidate.

There are several questions that should have been considered prior to a consult about a procedure that would require a breast implant.

What is your age?

Which implant type of implant are you interested in, Silicone or Saline?

What are your reasons or reason for having breast implant or implants?

Do you need reconstruction?

Is one side significantly different than the other?

If you have surgery are ready to accept the risks and benefits of surgery?

Are you will to accept the change associated with implants and that if there are issues and the need for removal that the appearance may not be desirable?

Can you accept that implants can potentially make it difficult to have mammograms?

Are you able to accept that you will more than likely need additional surgery because of aging, pregancy, significant weight loss or gain, and possibly implant problems?

Will you follow up after to surgery to see your Plastic Surgeon?

Do you have an active infection?

Are you a smoker?

Do you have problems with depression?

Do you have Rheumatoid arthritis, lupus, or other autoimmune disorders or disease?

Do you take medications like steriods, immunosuppressants or other medicines that would delay your ability to heal?

Are you pregnant or nursing?

 I have been pleased with the results of reconstruction of one side of a woman's breast using the entire lower abdomen.  Initially five years ago when I began using the DIEP Flap for breast reconstruction I would only use half of the abdomen for the breast reconstruction and preserve the other portion during the procedure only to remove it and discard it at the end. I began to have more and more women with less abdominal tissue who really desired the DIEP Flap.  I have found this to be an extremely rewarding operation for the patients and for me.  Now I feel like I am utilizing all of the abdominal tissue even when I am reconstructing only one side for the patient.  This added volume allows for a better initial result and less complicated procedures down the road to provide symmetry.  Of course whenever possible and accordance with the patients desires we try improve in symmetry problems by using the patient's own fat.  This fat is harvested and separated into smaller portions then loaded back into smaller syringes and strategically placed to provide symmetry.

I have seen several patients recently after immediate breast reconstruction with a DIEP flap.  i am always impressed at how natural the appearance of the flap is in relationship to the other breast.  Many times I care for patients in other communities such as Greenbay, Sheboygan, Two Rivers, Appleton, and Madison, Wisconsin after mastectomy.  Many patients travel to have these procedures done at Froedtert and the Medical College of Wisconsin.  There is an entire team devoted to women with breast cancer.  Our goal as Plastic Surgeons is provide all available breast reconstruction options to each patient.  Many of our patients choose the DIEP flap because of our experience with the procedure.  We having been performing this procedure routinely over the past five years at Froedtert and the Medical College of Wisconsin.  Whether we need to perform simultaneous reconstruction of bothe sides or perfor a stacked or double diep flap on one side we have the team available.

There is a report today on CNN.com that  Task force opposes routine mammograms for women age 40-49.  The task force states that about 15 % of the time women age 40 will detect breast cancer.  other women will experience false positives, anxiety, and unnecessary biopsies.  This task force differs in its recommendations compared to the American Cancer Society which recommends mammograms stating at age 40.  This will invariably cause problems with insurance plans, their patient's desire for mammography, and the ability of the phsician to recommend what they feel is appropriate.  My personal experience is that the youngest woman I have operated on with the diagnosis with breast cancer is 24.  Fortunately she survived and went on to have reconstruction as well.