Reconstruction of periorbital region defects: A retrospective study.

BACKGROUND: Although the periorbital region forms less than 1% of the total body surface, it has a very complex anatomy; therefore, it requires a detailed approach. In this work, we aim to present the clinical applications and related literature for the algorithm of the technique which will be applied, according to the location of the defect, in choosing the surgery treatment method. Factors affecting the results and different treatment methods of the anatomical region, including its difficult reconstruction, will also be included. MATERIALS AND METHODS: A review of 177 periorbital region defect reconstructions was performed. RESULTS: As a treatment method, in 76 (43%) patients primary closure was chosen, 39 (22%) patients had grafts and in 62 (35%) patients a flap was chosen as a treatment alternative. With respect to postoperative complications, there were a total of 6 (3.38%) patients observed with venous congestion. In 11 (6.21%) patients ectropion developed, in 1 (0.56%) patient minimal space between the eyelids while monitoring recovery was observed and in 1 (0.56%) patient, flap loss was observed due to a circulatory disorder. CONCLUSIONS: The aim of reconstruction is to repair the defect suitable to normal physiological and anatomical values. As a result, before the surgical treatments in this difficult anatomical region, the defect width and anatomical localization must be evaluated. The most suitable reconstruction method must be identified, using an evaluation of the algorithm and the required functional and esthetical results can be obtained with intraoperative flexible behavior and a change of method, when necessary.

Orbicularis oculi myocutaneous advancement flap for upper eyelid reconstruction.

BACKGROUND: Reconstruction of large full-thickness defects of the upper eyelids is challenging because of their complex anatomy and specialized functions. The authors present and discuss a new, simple surgical technique for upper eyelid reconstruction. This is a single-stage procedure and has produced satisfactory to excellent results in the authors' patients. It presents the reconstructive surgeon with several advantages over other techniques. METHODS: The eyelid tumor is excised surgically until clear margins are obtained. The V-shaped orbicularis oculi myocutaneous advancement flap is marked on the remaining superior eyelid tissue and mobilized, leaving the base of the pedicle intact with submuscular tissue attachment. Posterior lamella reconstruction is performed with mucoperiosteal graft harvested from the hard palate in patients with full-thickness defects. Then, the flap is advanced to the defect and the donor site is closed primarily. RESULTS: Eight patients, aged 17 to 72 years, have been operated on with this technique for upper eyelid reconstruction. Follow-up included assessment of position, closure, length of palpebral rim, eyelid opening, aesthetic balance, presence of corneal erosion, ulcer or entropion, levator function, and donor-site morbidity. The flap was viable in every patient, without total or partial necrosis. No patient required surgical revision. The oncologic result was good, and no recurrence was noted. CONCLUSIONS: This method is a simpler, single-stage operation; does not damage the lower lid; provides a thin, mobile eyelid; and, above all, is less invasive than other techniques, and at the same time allows a good functional and aesthetic reconstruction.

Reconstruction of the columella with bilateral nostril sill flaps.

The treatment of total columellar defects is very difficult, and there is not any first choice in reconstruction of these defects. Various techniques have been reported for this purpose. Each technique has its own drawbacks, and few can be performed in one stage. We report a pediatric patient with a defect involving the entire columella. Reconstruction of the defect was accomplished with laterally based bilateral nostril sill flaps. An acceptable cosmetic result was obtained. This method can be done as a single-stage operation with an excellent color and texture match. We think that this method leads to good aesthetic results, and should be considered for total columellar reconstruction.

Use of medial arm skin as a free flap.

BACKGROUND: Free transfer of the medial arm flap has not gained popularity despite the hidden donor-site scar as well as the hairless and elastic skin. This may be because of variations in vascular anatomy, leading to confusion during dissection of the flap. METHODS: In five preserved cadaver arms, the vascular pattern of medial arm skin was examined. Twenty-two upper extremity angiograms were examined, and 12 free medial arm flaps were elevated for various defects in 12 patients. RESULTS: In cadaver and clinical dissections, the authors found that blood supply to the flap is multiple: from the superior ulnar collateral artery, the direct cutaneous artery, or both. A superficial brachial artery may also be present, which was observed in four angiograms and two clinical cases (15 percent). Dissections showed that the medial arm skin may be elevated based on the superficial brachial artery, direct cutaneous artery, or superior ulnar collateral artery. A neurosensory flap may be obtained by including the medial brachial cutaneous nerve of the arm. CONCLUSIONS: A medial arm free flap is a plausible reconstructive option with good knowledge of the anatomical variations, as the defect on the medial arm is cosmetically more acceptable and has a better color match for head and neck reconstructions.

Block and Surgicel-wrapped diced solvent-preserved costal cartilage homograft application for nasal augmentation.

BACKGROUND: Cartilage grafting has been used extensively to correct the nasal framework in traumatic and postrhinoplasty nasal deformities. Autologous cartilage grafts yield satisfactory reconstructive results, but their use is limited by donor-site morbidity, patient choice, the requirement for increased operative time, and the lack of a sufficient quantity and availability of tissue for more extensive deformities. Alternatively, preserved costal cartilage homograft represents a readily available, easily contoured material. METHODS: The preserved costal cartilage homograft has been used by the authors on 68 patients over the past 5 years: in 52 patients with postrhinoplasty deformity and in 16 patients with traumatic nasal deformity. In cases with more severe nasal depression, the cartilage graft was carved and placed over the remaining septum in block form. The "Turkish Delight" technique, which was initially described by Erol, was used in cases of mild to moderate nasal depression. The cartilage graft was diced into 0.5- to 1-mm pieces. The diced cartilage mass was then wrapped in Surgicel and inserted under the dorsal nasal skin. RESULTS: Follow-up ranged from 6 months to 5 years. During this period, no major complications were noted, and satisfactory results were obtained. Recurrence of the dorsal depression was seen in five patients and required repeated augmentation. The complication and revision rates were acceptable. CONCLUSIONS: This technique seems to be effective for augmentation of the nose, shortens the operative time significantly by eliminating graft harvest, and avoids donor-site morbidity. Therefore, it is recommended for nasal augmentation and contouring for traumatic and postrhinoplasty nasal deformities.

In vivo study to assess the viability and mass effect of fascia injection in comparison with block fascia graft.

Recently, fat injection has gained favor among plastic surgeons for soft tissue augmentation. However, fat injections lose 50% of their volume after 1 year. The profession is in need of an injectable bulking material that gives a long-lasting improvement. Using 30 male rats, this study investigated the stability of the size and structure of the injected fascia autograft and compared it with surgically transplanted fascia. The fascia graft was harvested from the back of the rat, big, and divided into two equal pieces. The first piece was minced into a paste and injected subcutaneously on the anterior surface of the right ear. The other piece was transplanted subcutaneously on the anterior surface of the left ear. The grafts were observed for any sign of resorption over 1 to 6 months.Grossly, injection and transplantation sites were palpable at the end of the observation periods. Microscopic examination showed that injected fascia maintains its histomorphologic structure. These findings indicate that the injected fascia graft is well tolerated, and the size of the graft remained stable. According to this study, fascia injection can result in bulking material that gives a long-lasting improvement, and can be a viable alternative to other methods.

Versatility of the lateral arm free flap in various anatomic defect reconstructions.

The free lateral arm flap may be harvested as a fascial, fasciocutaneous, or osteofasciocutaneous flap. Simultaneous flap elevation with preparation of the recipient site, easy dissection, minimal donor-site morbidity, and a constant vascular anatomy with long pedicle are advantages of the flap. In this study, the authors present 18 patients operated on between January, 2002 and August, 2003 in whom 18 free lateral arm flaps were utilized. There were four women and 14 men, and the mean patient age was 40 years. Thirteen fasciocutaneous, three fascial, and two osteofasciocutaneous flaps were used. Flaps were employed for the reconstruction of the lower extremity in five patients, upper extremity in nine patients, and head and neck in four patients. Thirteen flaps were elevated under axillary block and five flaps under general anesthesia. Aspirin, dipirydamol, dextran, and chlorpromazine were administered postoperatively. Venous insufficiency developed in two lower-extremity reconstructions on postoperative day 1. Venous thromboses were detected, anastomoses were re-done, and flaps healed uneventfully. No other postoperative complication was observed in the other patients. The free lateral arm flap may be used in various anatomic defects with various indications. It may be elevated under axillary block for extremity reconstructions.

Repair of pharyngocutaneous fistulas with the submental artery island flap.

Pharyngocutaneous fistulas after total laryngectomy are difficult to manage and are a cause for significant morbidity to the patient. When fistulas fail to close with conservative measures, debridement and flap closure are indicated. Although a number of techniques to repair pharyngocutaneous fistulas are described, each of these procedures has its drawbacks. The authors have used the submental island flap to close postoperative pharyngocutaneous fistulas in nine male patients during the past 4 years. The mean patient age was 65 years (range, 57 to 75 years). The submental island flap is based on the submental artery, a branch of the facial artery. The inner aspect of the fistula was initially formed using hinge flaps on the skin around the fistula. Once a watertight closure of inner side was created, the skin defect was closed with the submental island flap. The maximum flap size was 6 x 3 cm and the minimum size was 4 x 2 cm (average, 4.8 x 2.7 cm) in this series. Direct closure was achieved at all donor sites. Patients were followed for 6 months to 4 years. No major complication was noted in the postoperative period. All patients have successfully recovered their swallowing function. The submental island flap is safe, rapid, and simple to elevate and leaves minimal donor-site morbidity. The authors believe that this technique is a good alternative in the reconstruction of pharyngocutaneous fistulas. Application of the technique and results are discussed.

Rare case of intramasseteric cavernous hemangioma in a three-year-old boy: a diagnostic dilemma.

Intramuscular hemangiomas are rare, benign tumors of vascular origin. The masseter is the muscle most commonly involved in the head and neck region. Because of their infrequency, deep location, and unfamiliar presentation, these lesions are seldom correctly diagnosed clinically. This case report presents a severe facial asymmetry caused by a left intramasseteric cavernous hemangioma in a 3-year-old boy. We were unaware of the exact nature of the tumor until intraoperative examination. The routine investigations performed before operation failed to establish a diagnosis. Surgical excision was performed, and 1 year after the operation we observed that the patient's facial asymmetry had been corrected. In this article, we review the literature on intramasseteric hemangioma, discuss the clinical and radiologic diagnostic methods, and review the treatment methods.

Hair-bearing submental artery island flap for reconstruction of mustache and beard.

Loss of mustache and beard in the adult male caused by severe burn, trauma, or tumor resection may cause cosmetic and psychological problems for these patients. Reconstruction of the elements of the face presents difficult and often daunting problems for plastic surgeons. The tissue that will be used for this purpose should have the same characteristics as the facial area, consisting of thin, pliable, hair-bearing tissue with a good color match. There is a very limited amount of donor area that has these characteristics. A hair-bearing submental island flap was used successfully for mustache and beard reconstruction in 11 male patients during the last 5 years. The scar was on the mentum in four cases, right cheek in two cases, right half of the upper lip in two cases, left cheek in one case, left half of the upper lip in one case, and both sides of the upper lip in one case. The submental island flap is supplied by the submental artery, a branch of the facial artery. The maximum flap size was 13 x 6 cm and the minimum size was 6 x 3 cm (average, 10 x 4 cm) in this series. Direct closure was achieved at all donor sites. Patients were followed up for 6 months to 5 years. No major complication was noted other than one case of temporary palsy of the marginal mandibular branch of the facial nerve. The mean postoperative stay was 7 days. Color and texture match were good. Hair growth on the flap was normal, and characteristics of the hair were the same as the intact side of the face in all patients. The submental island flap is safe, rapid, and simple to raise and leaves a well-hidden donor-site scar. The authors believe that the submental artery island flap surpasses the other flaps in reconstruction of the mustache and beard in male patients. Application of the technique and results are discussed in this article.