This is the Mount Sinai Division of Plastic and Reconstructive Surgery presenting our supplementary videos for our CME article discussing reconstructive management of amniotic band syndrome. In this third video, we will illustrate the important steps of the operative technique used by the plastic surgery team here at Mount Sinai for the treatment of amniotic band constriction rings in the extremity. While there are other options for technique, we have found that this one produces reliable and predictable results for eliminating the chance for soft tissue deficit. In the previous video, we demonstrated the preoperative incision markings made for routine operative management of amniotic band constriction rings in the extremity. Here we have marked the borders of the constriction band with some adjacent skin and soft tissue both proximally and distally to be included with the excision of the band itself. This allows for optimization of closure without tension and prevents the development of an hourglass deformity after healing. Z-plasties are marked on opposite sides of the ring as shown here. Again, the dots proximal to the band mark the area of harvest of the donor subcutaneous turnover flaps, which will be shown in this video. The initial step of the procedure includes incision down to the depth of the termination of the constriction band and excision of the band itself with the associated soft tissues. This step has been reported to range from involvement of the subcutaneous tissues only to all the way down to fascia with no intervening adipose tissue between the band itself and the fascia. Because of this varying depth of involvement, it is important to note that excision of the band itself poses the risk for exposing or damaging deeper structures in the extremity. Possible structures include neurovascular structures as shown here, in addition to tendons, ligaments, deep investing fascia, or bone. It is important to dissect meticulously in order to avoid any damage to these structures. Next, the dermal fat flaps are created. These allow for the filling of the dead space created with resection of the constriction band. Without any soft tissue filling of the remnant defect, patients are found to be at risk for the development of an hourglass deformity long-term. With this technique, the subcutaneous fat is released superficially from the adjacent skin. We recommend using a curved iris scissor for this step. Here you can see the beginning of the development of the flap. A superficial plane is created just deep to the dermis, which allows for the superficial release of the subcutaneous turnover flap. It is important to leave behind enough dermis and subcutaneous tissue attached to the superficial skin to keep the skin alive and well perfused, as these closures can sometimes have to withstand a mild amount of tension. We recommend continuing the flap release circumferentially in order to adequately fill the constriction band defect. Here you can see the release of the flaps. we recommend undermining the plane circumferentially to a depth of one to two centimeters. This should be tailored to the amount of tissue that was required to be excised during the resection of the constriction band itself. Here you can see the soft tissue release of subcutaneous fat. This allows for advancement and turnover of the flap and minimizes any tension closure. Next, the released dermal fat flaps are advanced to fill the soft tissue gap created when the constriction band is excised. The flaps can be approximated to the area of interest in order to secure them in position during healing. We recommend tacking the flaps down distally into the defect with either bicryl or monocryl suture. The skin is then approximated with monocryl suture. Here you can see the Z-plasty adjacent to the medial and lateral malleoli respectively. And here you can see that not only is the constriction band excised and the skin approximated, but the soft tissue defect created by the congenital lack of subcutaneous tissue from the constriction band is also filled by the advanced dermal fat turnover flaps. We then apply Dermabond and wrap the extremity in a Curlex and a loose ACE bandage. There's no indication for postoperative antibiotics and pain can be treated with Motrin or Tylenol as needed.

amniotic band syndrome

plastic surgery technique

dermal fat flaps

Z-plasty

post-procedure care