Reversed First Dorsal Metatarsal Artery Island Flap for First Ray Defects.

Reconstruction of the first ray is challenging because of poor skin laxity, bone and tendon exposure, and limited local flap options. Repair using full- or split-thickness skin grafts is generally not an option because of the bone and tendon exposure. Reconstructive options using local flaps from the distal foot area are restricted owing to insufficient soft tissue. Many reconstructive options have been described to overcome these difficult situations. We present 2 cases in which the great toe and first ray defect were repaired using a reversed first dorsal metatarsal artery island flap. The findings from these clinical cases and anatomic studies have shown that the reversed first dorsal metatarsal artery island flap is an alternative and suitable option for reconstruction of soft tissue defect of the distal foot, especially first and second ray defects, because it is thin and simple, has anatomic characteristics similar to those at the recipient site, and results in minimal donor site morbidity.

Immediate Perineal Reconstruction After Extralevatory Abdominoperineal Excision: Buried Desepidermised Fasciocutaneous V-Y Advancement Flap.

BACKGROUND: According to National Cancer Institute, there are approximately 39,800 rectal cancer cases per year, 25% of which will need an abdominoperineal resection (APR). The key to avoid most of the complications related to pelvic defect that occurs after APR is choosing an appropriate reconstruction option for perineum. This study aims to introduce an easily applicable flap option for closure to address postoperative pelvic defect in low rectal cancer. METHODS: This is a retrospective evaluation of 9 patients who have undergone perineal reconstruction for pelvic defects after extralevatory abdominoperineal excision with rectal cancer between 2014 and 2016. Reconstruction consists of a novel technique defined by our clinic, which is buried desepidermised fasciocutaneous V-Y advancement flap. RESULTS: All defects are closed successfully. Patients are followed postoperatively for complications such as perineal infection, wound dehiscence, seroma, perineal sinus, or fistula formation. Flaps are evaluated with magnetic resonance imaging postoperatively, for viability and effectiveness on defect closure. Mean follow-up time is 20 (±9) months. Mean average hospital stay is 8 (±2) days. We did not experience any total or partial flap loss or encounter any local complication related to the wound. CONCLUSIONS: Buried desepidermised fasciocutaneous V-Y advancement flap is a reasonably easy and time-saving operation. It is effective in filling the pelvic dead space while closing the sacral defect after APR and therefore decreases late term complications related to large perineal excision.

Preventing Suture Extrusion and Recurrence in Mustarde and Furnas Otoplasties by Using Laterally Based Postauricular Dermal Flap, Long-Term Results.

BACKGROUND: Prominent ear deformity (PD) is an unacceptable condition of pinna that affects 5% of the population and is associated with emotional stress, behavioral disturbances, and social restrictions in relationships. Conchal hypertrphy, inadequate formation of antihelical fold, earlobe placement ahead than it should be, or various combinations of these changes are main characteristics of PD. Many surgical techniques have been described for the PD.The authors' aim was to present laterally based postauricular dermal flap combination with cartilage-sparing methods and effectiveness of this technique in suture extrusion prevention and reducing the rate of recurrence with long-term results. METHODS: Forty-one patients had bilateral and 6 patients had unilateral PD, a total of 47 patients with a mean age of 14.48 were operated by using this combined procedure. A laterally based supraperichondrial dermal flap was prepared from a deepithelized elliptical postauricular incision. Mustarde and Furnas suture techniques were used solely for PD correction. The dissected laterally based dermal flap was fixed to the mastoid bone with sutures in stretched position after reshaping the auricular cartilage with sutures. RESULTS: The average helix-mastoid distance was (mm) 16.28 ±â€Š2.36, concha-mastoid angle was 25.71 ±â€Š0.96° on 12-month measurements. The helix-mastoid distance showed an increase of 1 to 3 mm, in the concha-mastoid angle measurements of 1° to 2°. Statistically significant changes were observed between the average preoperative, postoperative 1. month, postoperative 12. month helix-mastoid distances (mm), and month concha-mastoid angle (°) measurements (P = 0.0001). CONCLUSIONS: The laterally based postauricular dermal flap technique is an effective method to prevent suture extrusion and recurrence which are the most important complications of otoplasty procedure and easy to apply.

Aesthetic Unit-Based Reconstruction of Periorbital Defects.

PURPOSE: The aim of this study was to perform a retrospective analysis of patients who underwent periorbital area reconstructions, determine their sociodemographic characteristics, analyze the effects of defect etiologies and locations classified according to periorbital subunits on our reconstruction options, and to present our treatment outcomes and clinical experience. METHODS: A retrospective chart review of 23 patients operated in our department between January 2010 and March 2013 and underwent periorbital area reconstructions, was performed. In addition to the demographic characteristics of the patients; defect etiologies, locations according to Spinelli aesthetic subunits, and the degrees of involvement were determined. RESULT: Analysis of the reconstructive methods showed that primary closure with lateral cantholysis was performed in 1 patient with a defect involving less than 50% of zone 1 along with a partial defect involving less than 50% of zone 2. In another patient with a full-thickness defect involving 75% of zone 1, reconstruction was made with a temporally based monopedicle forehead transposition (Fricke) flap prepared from the lower eyelid, and a conchal cartilage graft. In 2 other patients with partial defects involving more than 50% of zone 2; reconstruction was made with full-thickness skin grafts taken from the retroauricular area. Four patients had full-thickness defects that involved 50% to 75% of zone 2; 3 of them were reconstructed with a Tenzel lateral semicircular rotation flap and 1 with a Tripier flap. In 3 patients who had full-thickness defects involving 75% of zone 2; reconstruction was made with a paramedian forehead flap and conchal cartilage graft. In 3 patients with full-thickness defects involving more than 75% of zone 2, a Mustarde cheek rotation flap was used for reconstruction. Six patients had defects in zone 3, 3 of them were reconstructed with a glabellar flap, 2 with a paramedian forehead flap, and 1 with a bilobed flap. One patient with a defect that involved 50% of zone 4 was reconstructed with a McGregor flap. CONCLUSIONS: Construction of a reconstructive algorithm by separation of the eyelid into aesthetic units and use of local healthy tissues provide functionally and aesthetically acceptable results.

Recurrent Ameloblastoma in the Free Fibula Flap: Review of Literature and an Unusual Case Report.

Ameloblastoma is the second most common odontogenic tumor of the oral cavity with the primary site being the mandible. The ratio of maxillomandibular involvement however is 5:1 in favor of the mandible. The most common complaint is a painless swelling over the mandibular area. Despite its benign nature, ameloblastoma has a high local recurrence rate, with the most recurrences seen within 5 years after operation. Biopsy and radiological evaluation may be helpful in differentiating the subtypes of ameloblastoma. Differentiation is important because some subtypes are more aggressive than the others. Preoperative planning may be done according to this classification, which can help decrease the recurrence rate. In our case, a 26-year-old female patient with recurrent ameloblastoma which developed on the fibular flap is presented. The free fibular flap and the left parasymphyseal part of the mandible were totally excised. Ameloblastoma was confirmed on pathological examination. We reconstructed the left mandibular site with a reconstruction plate and recurrence was not seen during follow up period.

Ulnar nerve compression at the elbow caused by the epitrochleoanconeus muscle: a case report and surgical approach.

Cubital tunnel syndrome is the second most common peripheral nerve compression syndrome. It is the most common peripheral neuropathy of the ulnar nerve. The surgical treatment of the cubital tunnel syndrome is widely described in the literature, however the variations of the standard muscular anatomy in the medial humeral epicondyle region may create technical difficulties during surgical management. The epitrochleoanconeus muscle, which is an aberrant muscle of this region, is a rare cause of cubital tunnel syndrome. A case with ulnar nerve compression at the elbow caused by an uncommon etiological factor, hypertrophic epitrochleoanconeus muscle, and its surgical management is reported.

New otoplasty approach: a laterally based postauricular dermal flap as an addition to Mustarde and Furnas to prevent suture extrusion and recurrence.

Prominent ear is the most common deformity of the external ear. The major causes can be an underdeveloped antithetical fold, concha hypertrophy, and prominence of the ear lobule. Since Ely's first aesthetic correction of the prominent ear in 1881, more than 200 different techniques have been described, but the choice of procedure still remains the surgeon's preference. This report presents the laterally based posterior auricular dermal flap technique as an adjunct to the conventional cartilage-sparing otoplasty. An elliptical skin incision was planned according to the classic prominent ear correction technique. Instead of the excision, skin was deepithelialized. From the inferior border of the incision, the dermal flap was incised and elevated in a medial-to-lateral direction. The posterior auricular dermal flap was used to support and cover the suture material. This method was used in the treatment of 17 consecutive patients. After a follow-up period of 6-32 months (mean 16 months), the patients were evaluated in terms of the recurrence and suture line problems. No suture line problems or recurrences were observed at the end of the follow-up period. Use of the posterior auricular dermal flap both prevents suture extrusion and decreases recurrences. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effects of palatine bone denudation repair with periosteal graft on maxillary growth: an experimental study in rats.

BACKGROUND: The long-term goal of cleft palate repair is to provide normal maxillary growth and speech capacity. However, most surgical repairs of cleft palate result in areas of bone denudation on lateral aspects of the hard palate. It is widely acknowledged that palatal bone denudation and subsequent scar contracture resulting from cleft palate surgery can inhibit maxillary growth. METHOD: This study is designed to investigate the effect of the periosteum on growth patterns of the maxilla. A total of 32 three-week-old Sprague-Dawley rats were randomly divided into a control group and three experimental groups: a mucosa excision group, a mucosa-periosteum excision group and a periosteal graft group. Nine weeks postoperatively the skulls were prepared for study and palatal widths and lengths were determined. The experimental groups were investigated for various histological changes. RESULTS: There was no statistically significant difference for the maxillary measurements (palatal width and length) between the mucosa excision group and the periosteal graft group when compared with the control group. However, the mucosa-periosteum excision group compared to the control indicated a statistically significant decrease in the same measurements. There was also a statistically significant difference for the maxillary measurements between the periosteal graft group and the mucosa-periosteum excision group. It was demonstrated histologically that the density of the Sharpey's fibres and periodontal scar tissue showed a slight increase in the mucosa excision group and the periosteal graft group compared with the control group. In the mucosa-periosteum excision group, the density increased significantly as expected. CONCLUSIONS: All of these findings testify that retaining the periosteum or replacement with a periosteum graft after surgery can prevent the inhibition of maxillary growth.

Triphalangeal thumb with polydactyly: an alternative surgical method.

Triphalangeal thumb (TPT) is congenital hand anomaly which a thumb consists of three phalanges. Thumb appearance can differ widely; the thumb can be longer than usual or it can be deviated in the radio-ulnar plane. Thumb strength and function can be significantly diminished. The goals of surgical treatment are to reduce the elongated thumb length, establish normal thumb function, maintain a stable joint and improve thumb position if necessary. In general, surgical treatment is performed for improvement of thumb function. The case presented here had a TPT with pre-axial polydactyly. The TPT was well developed but it had no movement at the proximal or distal interphalangeal joints. The rudimentary thumb had a well-developed and functioning interphalangeal (IP) joint. So as an alternative surgical technique we planned to transfer the functioning IP joint of rudimentary thumb to the TPT.

Two-stage total prosthetic reconstruction of temporomandibular joint in severe and recurrent ankylosis.

Temporomandibular joint ankylosis is a devastating condition for the patient associated with both functional disability and aesthetic deformities. Various techniques have been described in the literature to overcome this problem; however, there is still a high risk of reankylosis in patients undergoing multiple temporomandibular joint operations, severe heterotopic ossification, and fibrosis of the soft tissues. This study includes 5 patients with severe and recurrent ankylosis. Two-stage reconstruction with excision of the bony mass and placement of a distraction device in the first stage, followed by gradual distraction of soft tissues, and placement of a total joint prosthesis in the second stage were performed in all patients. The 2-step approach helps to overcome the fibrosis and adhesions in the soft tissues and allows placing an implant with a higher ramus component. This approach seems to be a useful and effective technique for the management of such patients with high risk of reankylosis.

Reconstructive procedure of lower lip defect due to ecthyma gangrenosum--a rare complication of acute lymphoblastic leukemia.

Ecthyma gangrenosum is a rare invasive cutaneous infection mostly caused by Pseudomonas aeruginosa in immunosuppressed patients, especially during neutropenic states. Embolic lesions usually accompanying with septicemia of P. aeruginosa are typically painless, round, and centrally necrotic with a surrounding erythematous halo. Facial involvement occurred only in 6% of the patients, which may result to complicated defects for reconstruction. In this article, we aimed to present a case with relapse of acute lymphoblastic leukemia presented to our clinic with 50% defect of the lower lip due to ecthyma gangrenosum and its late-term reconstruction.

Covering the gold weight with fascia lata graft in paralytic lagophthalmos patients.

Loading the eyelid with a gold weight is a popular technique for improving closure of the eyelid in patients with facial palsy. Despite it being both safe and simple, placement of the weight into a submuscular pocket is not always successful. Ulceration of the skin, and extrusion and visibility of the implant, are quite common short or long-term complications. We have developed a technical refinement of lid-loading. After the implant has been sutured in the appropriate place, we cover the implant with a fascia lata graft. We have used this technique in 8 patients who had had excision of an acoustic neuroma. No implant ulcerated or migrated, and none of the patients complained that the implant was visible during follow up of between 3 months and 4 years. Tendinous grafts act as a strong barrier to the gold weight because they are durable and thick. Fascia lata is easily harvested and leaves an inconspicuous scar at the donor site. We therefore recommend the technique to avoid complications.

Isolated congenital partial absence of the left lower lateral nasal cartilage: case report.

Isolated congenital nasal anomalies are rare; the isolated absence of any specific nasal structure is even rarer. In this report, we present a patient with congenital isolated partial absence of the left lower lateral cartilage including only the lateral crura.

The use of subcutaneous pedicle rhomboid flap in the treatment of postburn scar contractures.

PURPOSE: To investigate the efficacy and versatility of subcutaneous pedicle rhomboid flap in the treatment of linear or wide postburn scar contractures located in various parts of the body. MATERIALS AND METHODS: Twenty-three patients (aged 5 to 35 years) with postburn linear and wide scar contractures were treated with 31 subcutaneous pedicle rhomboid flaps. Rhomboid flaps were applied in the trunk (4 flaps), head and neck (5 flaps), lower extremity (5 flaps), and upper extremity (17 flaps). In 3 cases, Z-plasty was incorporated to the technique due to inadequate release. RESULTS: All rhomboid flaps healed uneventfully. In 28 contractures, rhomboid flaps alone were efficient to release the tension line (90.3%). Tip necrosis of the triangular flaps of Z-plasty in 1 case was the only complication seen that later led to recontracture. CONCLUSION: Clinical results indicated that subcutaneous pedicle rhomboid flap is a simple, efficient, and versatile technique in release of any postburn scar contracture. As no undermining is carried out, the flaps are more reliable than commonly used Z-plasty. Again contrary to Z-plasty, displacement of anatomic landmarks such as axillary hair and areola is rare with the technique.