Management of cranial bone defects: a reconstructive algorithm according to defect size.

INTRODUCTION: Reconstruction of cranial bone defects is one of the most challenging problems in reconstructive surgery. The timing of reconstruction, the location of the defect, the materials to be used, and the medical history of the patient are parameters that have been mostly discussed in the literature. To the best of our knowledge, there has not been any published classification for the cranial bone defect reconstruction according to defect size. MATERIALS AND METHODS: Twelve patients underwent reconstruction of cranial vault defects. Cranial bone defects were classified into 3 groups according to the size of the defect. The small-sized group included the defects smaller than 25 cm(2), the medium-sized group included the defects between 25 to 200 cm(2), and the large-sized group included the defects larger than 200 cm(2). The small-sized defects were reconstructed with split calvarial graft, demineralized bone matrix, or hydroxyapatite cement; the medium-sized defects were reconstructed with split calvarial graft or allogenic bone graft; and the large-sized defects were reconstructed with methyl methacrylate, autoclaved bone, or porous polyethylene. RESULTS: Two patients needed revision for irregularities with demineralized bone matrix. Other patients had no skull defects or irregularities for which revision was suggested. CONCLUSIONS: We believe that the size of the defect is important for the reconstruction of cranial vault defects and that using a standard algorithm can increase the success rate.

External Mustarde suture technique in otoplasty revisited: a report of 82 cases.

In otoplasty surgery the antihelical fold is frequently created using Mustarde sutures. When using the Mustarde suture technique it is important to insert the needle through the cartilage at right angles. This technical objective is easily achieved with an external Mustarde suture technique. A review of 82 patients who underwent otoplasty between 2005 and 2011 was conducted. All patients underwent external Mustarde suture otoplasty without conchal cartilage resection. The cartilage had been softened by rasping and conchomastoidal sutures had been used to correct conchal excess if necessary. In one patient, a secondary revision was performed for inadequate superior pole correction. In three patients sutures were visible after 1 year postoperatively and the sutures were removed under local anaesthesia without any recurrence. In one patient blister formation occurred due to inaccurate packing, but healed without any problem in a few days. No other complications, such as bowstringing of the internal sutures, haematoma, or infection, were observed. The patients expressed a high degree of satisfaction with their results. The risk of technical error is minimal. It is easy to perform and not time-consuming. Due to these advantages, this method is a reliable technique in otoplasty.

Effects of different surgical techniques on cephalic index and intracranial volume in isolated bilateral coronal synostosis model.

BACKGROUND: Bilateral coronal synostosis (brachycephaly) is the most common single-suture synostosis that may lead to functional deficits such as mental retardation. This increases the importance of volume gain during surgery. This study was designed to understand the differences in volume gain, cranial index (CI), and aesthetic outcomes when additional osteotomies or rotations are applied on the frontoparietal segment. METHODS: Acrylic brachycephaly models were prepared. Frontoparietal osteotomy was standard in all models. Frontoparietal segment was fixed: to the same position in surgical control model, after 1.2-cm advancement in advancement model, after 180-degree rotation without advancement in rotation model, after 180-degree rotation plus a horizontal osteotomy and 1.2-cm advancement in rotation plus angled advancement model, and after a horizontal osteotomy without rotation and 1.2-cm advancement and in angled advancement model. RESULTS: Intracranial volume changes (in milliliters) and CIs were as follows between groups: control group, 828/94.1; surgical control group, 830/93.8; advancement model, 900/84.5; rotation model, 834/89.1; rotation plus angled advancement model, 897/82.7; angled advancement model, 902/81.8. CONCLUSIONS: Advancement of the frontoparietal segment is the keystone of surgery in brachycephaly treatment. Making an additional horizontal osteotomy can angle this segment and may supply additional volume gain. Rotation of the frontoparietal segment does not provide additional volume or CI gain but increase better aesthetic outcomes.

Evaluation of the nose profile after maxillary advancement with impaction surgeries.

OBJECTIVE: The aim of this study was to identify and quantify nasal profile changes following maxillary advancement (MA) and maxillary advancement with impaction (MAI) with Le Fort I osteotomies. METHODS: The study consisted of preoperative and postoperative lateral cephalograms of 42 class III adult patients. The study sample was divided into 2 groups, with the first group composed of 22 patients who underwent MA surgery and the second group composed of 20 patients who underwent MAI surgery. In total, 7 skeletal parameters and 17 soft-tissue parameters related to nasal projection, hump, dorsal convexity, and the nasolabial region were evaluated on the cephalograms, and hard- and soft-tissue relationships were assessed. RESULTS: Nasal length, hump, nasal depths, distance from the most convex point of the Alar curvature to the most inferior point of the nostril, alar curvature-subnasale, and subnasale-pronasale measurements decreased postoperatively. In the MAI group, MA correlated with significant decreases in nasal length and hump. In the MA group, MA correlated with pronasale position (P < 0.05); significant decreases in nasal depth, columella convexity, and subnasale-pronasale length; and significant changes in subnasale position. CONCLUSIONS: There is little difference in the effects of the 2 different maxillary surgeries on the postoperative nasal profile.

Sliding alar cartilage (SAC) flap: a new technique for nasal tip surgery.

Congenital anatomic deformities or acquired weakness of the lateral crura of the lower lateral cartilages after rhinoplasty could cause alar rim deformities. As lower lateral cartilages are the structural cornerstone of the ala and tip support, deformities and weakness of the alar cartilages might lead to both functional and esthetic problems. In this article, we are introducing sliding alar cartilage flap as a new technique to reshape and support nasal tip. One hundred sixty consecutive patients between 18 and 55 years of age (mean age: 27.51) were included in the study between January 2007 and May 2008. Of the total number of patients 60 were male and 100 of them were female. None of the patients had rhinoplasty procedure including lower lateral cartilage excision previously. Sliding alar cartilage technique was used in an open rhinoplasty approach to shape the nasal tip in all patients. This technique necessitates about 2 to 3 minutes for suturing and undermining the alar cartilages. The follow-up period was between 4 and 18 months. In no patients any revision related to the sliding alar cartilage technique was required. Revision was applied in 3 patients due to thick nasal tip skin and in one patient due to unpleasant columellar scar. In this article, we are presenting the "sliding alar cartilage flap" as a new technique for creating natural looking nasal tip. This technique shapes and supports nasal tip by spontaneous sliding of the cephalic portion of the lower lateral cartilage beneath the caudal alar cartilage, with minimal manipulation, without any cartilage resection, or cartilage grafting.

Resorbable mesh plate in the treatment of blow-out fracture might cause gaze restriction.

Selection of the material for the reconstruction of orbital floor defects is controversial. There are both autogenous and alloplastic materials, each having its own benefits and disadvantages. Resorbable mesh plate is one of the alloplastic implants. Although it has many advantages, the considerable complication related to the mesh is local inflammatory reaction along the infraorbital rim.We present a patient treated using resorbable mesh plate for the orbital floor fracture, in whom gaze restriction in the eye movements was detected because of some fibrotic bands passing through holes of the resorbable mesh.

Distally based lateral and medial leg adipofascial flaps: need for caution with old, diabetic patients.

BACKGROUND: Reconstruction of defects around the ankle region has always been challenging for plastic surgeons. Distally based lateral and medial leg adipofascial flaps are among the flaps of choice for coverage of this difficult region. Presented here is the authors' clinical experience with these flaps, particularly emphasizing the complicated attempts in diabetic patients. METHODS: Seven skin defects around the ankle were reconstructed with lateral and medial leg adipofascial flaps. The lowermost perforators of the peroneal or posterior tibial artery were identified preoperatively, and a straight incision through skin only was made proximal to this perforator. With the skin flaps reflected, the adipofascial flap was than raised in the subfascial plane. The perforators to be retained in the base were located and the flap was then turned over to cover the defect, followed by application of a split-thickness skin graft over the flap. The donor site was closed primarily. RESULTS: The ages of the patients ranged from 25 to 80 years, and the size of the flaps ranged from 3 x 5 cm to 7 x 10 cm. Four defects were reconstructed with lateral leg adipofascial flaps, and medial leg adipofascial flaps were used in three. Two flaps healed uneventfully. Partial or total graft loss and partial flap necrosis were observed in five patients, four of whom were diabetic. CONCLUSIONS: Leg adipofascial flaps offer a valuable option for repair of defects around the ankle in many cases. However, adipofascial flaps should be used with caution in old, diabetic patients and, when performed, the probability of a second or third procedure should be considered.