Category: Plastic surgery

After the second lobe is elevated, the surgeon can inset the two lobes (Figure 9). The defect left from the second lobe should be closed primarily. Sometimes a Burrow’s triangle or V-Y advancement flap may be used to close this defect if the edges will not come together without tension. Trimming the flaps and the dog ears or cone defect resulting from the rotation may be necessary. Suture selection usually consists of absorbable 4-0 inverted interrupted sutures in the deep dermis, while nonabsorbable 5-0 monofilament sutures are usually used to close the epidermis in simple fashion (Figure 10). The skin sutures are removed five to seven days postoperatively.

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The second key step in this procedure is undermining the primary defect to avoid pin cushioning. Pin cushioning is caused by either an excessively large flap, or scar contraction, which leads to constricting forces developing along the inner aspect of a curved scar. With time, the tissue or flap within the curve bunches together and protrudes, leading to the pin cushion phenomenon. Pin cushioning can be avoided by undermining the tissue of the primary defect and ensuring that the flap is not too large for the defect. This allows the defect_to expand outwards, and the undermining provides room for the new flap skin to settle in the same plane as the primary defect.
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Local anesthesia is used with epinephrine for hemostasis, creating a tumesencent bed over the entire surgical area including the defect, flaps both flaps and surrounding tissues that will need to be undermined to facilitate skin movement and closure. The local anesthetic will have time to take effect while the patient and the the surgical field are prepared.
The lesion is then excised and sent for pathology to verify clear margins (Figure 4). Hemostasis is obtained with bipolar cautery forceps.
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The two lobes of the skin flap are then planned and outlined adjacent to the lesion. The lobe distal to the wound is smaller in size than the proximal lobe. The bilobed flap is outlined with a surgical marker (Figure 3).
The first or proximal lobe, used for reconstructing the defect, usually lies with its midmark at 45° or less to that of the defect. The distal or second lobe used to repair the defect resulting from the first lobe is taken from the loose skin donor site. This lobe is transposed 45° to the defect from the first lobe.

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cheek defects (part 2)

TECHNIQUE
The lesion is identified (Figure 1) and marked with appropriate margins from the clinically visible tumour border (Figure 2). Loupe magnification may be used to help delineate the lesion border. The skin should be assessed for laxity, tethering and mobility. In this case, areas of laxity were assessed. Due to the nature of the skin and previous treatments, the best area of recruitment was on the lower cheek and inferior preauricular region . Proximal to the lesion (superior), the skin was taut and unsuitable for easy closure. A ‘pinch test’ also provides an estimate of the thickness of the skin and subcutaneous tissues. You are always welcome to shop for efficient medications and buy mircette here at the best pharmacy you could ever come across, making your purchase with confidence and always be sure you will be taken great care of as a customer.
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The usefulness of the bilobed flap for lateral cheek defects (part 1)

Head and neck skin cancer excision and reconstruction provide endless challenges and opportunities for the reconstructive surgeon. There are many, well-documented methods of excision and reconstruction. These methods are based on the principles of the reconstructive ladder and on geometric principles. Factors such as tissue quality, size of defect and relevant anatomical structures, as well as cosmetic subunits, must all be considered.
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Ischemic heart disease remains the most common cause of death for women in developed countries. Despite current trends in percutaneous coronary intervention and the recent popularity of drug-eluting stents, the strongest, most robust evidence with the longest follow-up still fervently supports coronary artery bypass surgery as the gold standard therapy for left main coronary artery disease, triple vessel disease and two vessel disease with proximal left anterior descending artery involvement. Evidence regarding the superior patency of IMA grafts over any other conduit or intracoronary revascularization mechanism is clear. Recent studies have suggested patency rates of between 95% and 99% at 10 years , and 88% patency at 15 years. Alternatively, saphenous vein grafts have an expected patency rate of approximately 50% to 60% at 10 years. The most persuasive information about the left IMA graft is that, unlike saphenous vein grafts or coronary stents, the left IMA-left anterior descending bypass is the only form of coronary revascularization that has been associated with improved early and late patient survival. In general, most cardiac surgeons reserve bilateral IMA grafting for young, nondiabetic patients with an appropriate body habitus.

CONCLUSION
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