True functional reconstruction of total or subtotal glossectomy defects using a chimeric anterolateral thigh flap with both sensorial and motor innervation.

BACKGROUND: The purpose of this study was to report the motor functional outcomes and sensory recovery of patients who had undergone total or subtotal glossectomy for oral squamous cell carcinomas reconstructed with chimeric anterolateral thigh (ALT) flaps. METHODS: Six patients, 4 men and 2 women, with a mean age of 49.5 years (range, 36-73 years) were included in the study. All patients were treated with chimeric ALT, including the vastus lateralis muscle with its motor nerve and skin paddle with its innervating nerve. All patients were administered functional tests involving sensory recovery, intelligibility, and swallowing. Flap sensibility was evaluated using light touch sensation with the Semmes-Weinstein monofilament test, 2-point discrimination according to the Weber sensitive test, warm and cold temperature sensations, and pain sensation. Intelligibility was scored by a speech therapist on a scale from 1 to 5. Swallowing was assessed by electromyography, deglutition scores (on a scale of 1 to 8), and modified barium swallow. Donor-site morbidities were recorded. RESULTS: Mean follow-up was 26.6 months (6 months-5 years). The flaps were successful in all 6 patients. The donor site was closed primarily and no complications were seen in the follow-up period. Normal extension of the knee joint and no evidence of lateral patella instability occurred. Speech intelligibility was good (4) in 3 patients and acceptable (3) in 3. Deglutition scores were 6 in 2 patients, 5 in 2, and 4 in 2. Modified barium swallow revealed that 4 patients experienced bolus transit, but 2 required a liquid swallow to promote bolus transit. Electromyographic recordings showed innervations of the vastus lateralis muscle with active generation of motor unit potentials in 4 patients when trying to elevate the tongue. This was not performed in 1 patient, and 1 other had macroscopic muscle contractions. All sensory tests were satisfactory in all parameters. CONCLUSIONS: The results of this reconstructive option were satisfactory in terms of motor function and sensitive assessment of the neotongue. This technique is strongly recommended for patients with total or subtotal glossectomy.

Reconstruction of fingertip defects with digital artery perforator flap.

OBJECTIVE: The aim of this study was to present our findings for the use of the digital artery perforator (DAP) flap in the covering of digital pulp defects. METHODS: The study included 15 patients who underwent reconstruction of the fingertip using a DAP flap between July 2007 and February 2012. The blood supply of the perforator island flap was based on the distal and either radial or ulnar sides of the digit. Donor sites were closed using skin grafting in all cases. Static two-point discrimination (s2PD) and Semmes-Weinstein monofilament (SWM) testing was performed at the final follow-up to determine extension loss and sensorial improvement. RESULTS: Mean follow-up was 22 (range: 7 to 62) months. Flaps size was between 2 x 1 cm and 2.5 x 1.5 cm. Temporary venous congestion was observed in 12 of the 15 patients and was without complication. All patients returned to their normal daily activities and work within an average of 39 (range: 30 to 45) days. Mean two-point discrimination was 5.3 mm and SWM test results were between 3.61 and 4.56 at the final follow-up. CONCLUSION: The DAP flap appears to be a reliable procedure with several advantages as a single-stage operating procedure, easy to harvest, good sensory recovery and preservation of digital arteries.

[Using pedicled rectus abdominis musculocutaneous flaps in thigh and lumber defects]. / Pediküllü rektus abdominis kas deri flebinin uyluk ve sirt defektlerinde kullanimi

BACKGROUND: A series of previously described but rarely used variations of the pedicled, extended or vertical rectus abdominis musculocutaneous flap (Extended RAM, VRAM) were reviewed. METHODS: Skin paddle dimensions, ranged 8 to 28 cm in width and 10 to 35 cm in length, were used in five consecutive patients. Four flaps were placed deep to the inguinal ligament to repair the thigh as proximal to the knee region; the remaining one flap was passed transabdominally to cover the defect of the lumbar region. RESULTS: No flaps necrosis were seen and in one case wound healing problems required minimal operative intervention. Successful transfer of the VRAM and extended RAM with low rate of complication for the thigh and lumbar region defects were demonstrated to be safe and reasonable options of flap reconstruction. DISCUSSION: The flaps had the advantages of being robust and well-vascularized, easy and fast to harvest, and not requiring microsurgery experience.

Management of neglected periorbital squamous cell carcinoma requiring orbital exenteration.

With its perineural invasion capacity, periorbital squamous cell carcinoma (SCC) may easily invade orbital structures. When SCC invades the orbital musculature or the orbit itself, orbital exenteration, one of the most disfiguring operations on the face, is required. We reviewed elderly patients with periorbitally localized SCC requiring orbital exenteration to evaluate reconstructive options and survival. A chart review of patients' records was conducted to identify all patients older than 65 years with periorbital malignancy requiring orbital exenteration from 2006 to 2011. A total of 9 patients who met the criteria were included in the study. The mean age at surgery was 77 ± 6.7 years, and the mean defect size was 74.2 cm2. All patients had a similar history of late presentation to a doctor because of hesitation to undergo surgery. The temporoparietal fascia flap, galeal flap, free gracilis flap, and free vastus lateralis musculocutaneous flap were the treatment options for reconstruction of the defects. All patients died during follow-up, and the mean survival was 15.7 months (range, 6-36 months). Only 2 of them had relapse before the death. Our small series suggest that elderly patients with periorbital SCC requiring orbital exenteration may not have enough survival to relapse because of the death from different causes without relapse or any sign of spreading cancer. Also, prolonged surgery with free flap reconstruction may increase the risk of postoperative intensive care unit requirement. Because local flaps may work very well for reconstructing the orbital exenteration defects, free flap option should be kept for selected cases.

Dermabrasion and staged excision of facial lesions in a neurofibromatosis case for improvement of facial appearance.

BACKGROUND: Neurofibromatosis may present with different skin lesions. Disfiguring lesions on the face might be challenging for the surgeon or clinician to correct and may have adverse effects on patients' social lives, especially in young women. OBJECTIVE: To present the dermabrasion technique combined with serial excisions of a deeper accompanying lesion to treat superficial facial lesions in a young neurofibromatosis patient. METHODS: Dermabrasion was applied to superficial lesions on the face, and staged excision was applied to the deeper lesion located on the forehead. RESULTS: We obtained high patient satisfaction with the result. The deep lesion was excised totally, and superficial lesions were decreased with dermabrasion. CONCLUSION: Dermabrasion may become a good alternative in cases of neurofibromatosis with superficial facial lesions.

Tendon transfer for the restoration of thumb opposition: the effects of friction and pulley location.

BACKGROUND: The authors compared the gliding resistance among three commonly used pulley sites used for oppositional transfers. METHODS: Eight fresh-frozen cadaver forearms were studied. The ring finger's flexor digitorum superficialis was used as a donor tendon in all specimens. An oppositional transfer was created to the thumb using three pulley sites: the Royle-Thompson, the Guyon canal, and the flexor carpi ulnaris tendon loop pulleys. The flexor digitorum superficialis was inserted into the palmar radial portion of the abductor pollicis brevis in all cases. Gliding resistance was then measured and compared. Final thumb position was measured to assess the amount of thumb palmar abduction and opposition created with each pulley configuration. RESULTS: The average gliding resistance of tendons passed within the Royle-Thompson, Guyon canal, and flexor carpi ulnaris loop pulley were 1.27, 0.58, and 0.44 N, respectively. Gliding resistance for the Royle-Thompson pulley was found to be significantly higher than that for the Guyon canal or flexor carpi ulnaris loop pulley (p < 0.05). There was no significant difference between the Guyon canal and flexor carpi ulnaris loop pulleys with regard to gliding resistance. The flexor carpi ulnaris loop pulley produced the greatest amount of palmar abduction (p < 0.05), whereas the Guyon canal and Royle-Thompson pulleys produced the greatest amount of thumb opposition. CONCLUSIONS: The Guyon canal and flexor carpi ulnaris loop pulleys produced lower friction than the Royle-Thompson pulley. The Guyon canal pulley produced greater thumb opposition compared with the flexor carpi ulnaris loop pulley and represents an ideal pulley site for restoration of thumb opposition.

Management of temporomandibular joint ankylosis with temporalis fascia flap and fat graft.

AIM: Temporomandibular joint (TMJ) ankylosis is a serious problem that restricts jaw mobility and causes disturbances in facial and mandibular growth. The purpose of this paper is to present an easy and versatile method for the treatment of TMJ ankylosis to decrease postoperative complications such as re-ankylosis. MATERIAL AND METHOD: Eleven patients who presented with ankylosis of the TMJ underwent surgical release. After performing gap arthroplasty through a preauricular approach, the temporalis fascia flap was transposed to the gap. An autogenous fat graft was then obtained from the abdomen and used as interpositional material. The follow-up time was 3-5 years. RESULTS: Re-ankylosis did not occur in any of the patients, and all had satisfactory mouth opening. CONCLUSION: Surgical treatment of TMJ ankylosis with gap arthroplasty, interposition of the temporalis fascia flap and fat grafting is an effective and easily procedure for preventing of re-ankylosis. The autogenous nature and close proximity to the joint are the main advantages of the temporalis fascia flap when compared with other interpositional materials, and the fat graft provides additional support by reducing pressure.

Preventing negative effects of smoking on microarterial anastomosis.

Although microsurgery has rapid expanded, problems related to microarterial anastomosis continue. Cigarette smoking is one of the major risks for anastomosis by increasing platelet adhesion, and its effects on endothelial cells. Aim of this article is to study the negative effects of cigarettes on microarterial anastomosis line, and to investigate the protective effects of recombinant human erythropoietin (rHuEPO).Ninety-six Sprague-Dawley male rats were divided into 3 groups: group 1 was the control. Rats in groups 2 and 3 were exposed to cigarette smoke starting 21 days prior to surgery for 3 times a day. In group 3, additional 150 IU/kg rHuEPO was given via subcutaneously every 48 hours after microvascular anastomosis, femoral arterial samples, and blood samples were taken for assessment at 1st, 3rd, 5th, and 7th day. Intimae/media ratios were calculated for morphologic analyses.On morphologic analysis of femoral arteries there were statistically significant differences for all 3 groups at 1st, 3rd, 5th, and 7th days (P < 0, 05). The group that made differences was group 2, according to one-way analysis of variance within 3 groups in all days.Smoking decreases endothelial cells healing and causes more thromboses. rHuEPO can prevent these negative effects of smoking.

[The reconstruction of soft tissue defects in the elbow area: a treatment algorithm proposal]. / Dirsek bölgesi yumusak doku defektlerinin rekonstrüksiyonu: tedavi algoritma önerisi.

BACKGROUND: The reconstruction of soft tissue defects of the elbow area (including antecubital fossa and peri-olecranon area) should be performed with the most appropriate soft tissue and functional rehabilitation immediately. METHODS: Ten patients were included in this study. One had a brachial artery defect, another had postburn axillary contracture deformity, and a third had an ulnar bone body fracture in addition to their soft tissue defects, while the remaining seven had only soft tissue defect. Patients underwent surgical closure either by local arm fasciocutaneous flap (1), radial forearm flap (1), multiple Z-plasty (1), pedicled latissimus dorsi muscle flap (3), or with the antecubital fasciocutaneous island flap (4). RESULTS: The follow-up was 9 months to 4 years (mean: 19 months). All the flaps achieved wound closure without losing the range of motion at the elbow joint. CONCLUSION: Surgical closure of the antecubital fossa and peri-olecranon areas can be a challenge for plastic surgeons since this area includes numerous neuro-vascular bundles and a functional joint. Therefore, we describe herein an algorithm for the treatment of defects in these areas from the inspiration in our clinical experience and a literature review. Our algorithm will help to decide the most appropriate choice among all of the surgical options available.

The effect of triangular fibrocartilage complex injury on extensor carpi ulnaris function and friction.

BACKGROUND: It has been previously shown that injury to the triangular fibrocartilage complex increases the moment arm of the extensor carpi ulnaris. This will reduce the force producing capacity of the muscle in some situations, but will also increase its mechanical advantage. It is also possible that the change in the tendon path may increase tendon friction, predisposing the patient to future repetitive motion injury. It is the purpose of this study to determine the effects of triangular fibrocartilage complex injury on extensor carpi ulnaris moment producing capacity and tendon friction. METHODS: A simple simulation was used to examine muscle moment producing capacity throughout the range of motion, at varying speeds and in both injured and healthy states. Six fresh frozen human cadaveric wrists were used to determine the effect of injury on tendon friction. A custom made device was used to move the wrists through a range of motion, while a constant force was applied to the proximal tendon and force was recorded at the distal tendon. Friction was measured before and after the creation of injury. FINDINGS: The decreases in muscle force following injury were small, even in the worse case. The moment producing capacity of the muscle was increased following injury. Tendon friction during flexion-extension was decreased following injury. The friction during radial-ulnar deviation was unchanged. INTERPRETATION: When making surgical decisions about triangular fibrocartilage complex repair, it is not necessary to consider extensor carpi ulnaris moment producing capacity or tendon friction.

Reconstruction of a "double pathology" on a soft palate: hairy polyp and cleft palate.

Hairy polyps of the head and neck are rare congenital tumors that may cause upper aerodigestive tract impairment in newborn. Although cleft palate is a common congenital anomaly, hairy polyp with cleft palate is extremely rare in the newborn. We aimed to present the planning of reconstruction in a patient who has an incomplete cleft palate and defect due to hairy polyp excision on soft palate in this report. A 9-month-old child was admitted to our clinic due to cleft palate. In the clinical examination, incomplete cleft palate plus a defect on the posterior side of the left soft palate was observed. On the history, the patient had been operated urgently at the newborn period for a hairy polyp localized on the left soft palate which had obstructed the airway. Wardill-Kilner-Veau technique was modified for the reconstruction of the defect on the soft palate and incomplete cleft palate. No complication was seen on postoperative period. The speech ability was evaluated on the late postoperative controls after 3 years and adequate speech intelligibility was obtained. A case of hairy polyp of nasopharynx with incomplete cleft palate in a neonate and its reconstruction techniques are discussed. The etiology of hairy polyp, hamartoma, teratoma, dermoid cyst and epignathus, their nomenclature, histopathology, clinical features, and management in neonates are also discussed briefly.

Parry-Romberg syndrome: facial atrophy and its relationship with other regions of the body.

Parry-Romberg syndrome (PRS) is an uncommon disorder and characterized by a slowly, an acquired progressive atrophy involving skin, soft tissue, cartilage, and bony structures. Accompanying atrophies of the other parts of the body are rarely reported. The aim of this study is to report a case that had contralateral lower extremity atrophy with PRS, and to review the related etiologic features, physiopathology, and mechanism. The patient who admitted for his facial atrophy also had atrophy of his contralateral extremity. This extremity was also short in length when compared with other extremity. To obtain detailed information regarding the severity of involvement routine laboratory investigations including antinuclear antibody (ANA), magnetic resonance imagine (MRI) of the craniofacial region and lower extremities, MR angiography of the lower extremities and brain, 3-dimension computed tomography (CT) scan of the craniofacial region were performed. Normal or negative laboratory findings included results of blood count, renal and hepatic function biochemical tests, rheumatoid factor, C-reactive protein, anti-dsDNA antibody except ANA that were positive. His lower extremity and brain MR angiography were normal. In the 3-dimensional cranial CT, there was no abnormality or defect in the bony structures. His brain MRI showed no pathologic changes, and his facial MRI demonstrated noteworthy atrophy to the sternocleidomastoid, masseter, pterygoid muscles, and subcutaneus soft tissues on the right side of the face. Additionally, MR investigation of his lower extremities revealed decreased volume in muscles and bony structures of the effected extremity compared with the other extremity, but pathologic evidence of fatty degeneration associated with muscle atrophy was not demonstrated. The patient had isolated contralateral lower extremity involvement combined with hemifacial atrophy (without affecting any other part of the body). Although more accepted theory is the sympathic nervous system dysfunction, autoimmunity may play a roll in the etiology of our case as ANA abnormality was found in multiple tests.

Free tissue transfer for lower extremity reconstruction: a study of the role of computed angiography in the planning of free tissue transfer in the posttraumatic setting.

BACKGROUND: Computed tomographic angiography can be used as a means of assessing lower leg vasculature before performing free tissue transfer, but its reliability within a trauma setting has not been evaluated. The aim of this study was to examine the findings of preoperative computed tomographic angiography and correlate these findings to flap survival and limb salvage. METHODS: Seventy-six consecutive lower extremity trauma patients underwent preoperative computed tomographic angiography before free flap reconstruction. Arterial inflow, venous outflow, and the incidence of traumatic occlusion were recorded. Flap survival rates, limb salvage, and postoperative complications were noted. RESULTS: There were no complications associated with the computed tomographic angiography procedure. Computed tomographic angiography demonstrated normal vascular anatomy in 40 patients (52.6 percent), anatomical variants in seven patients, and atherosclerotic occlusive disease in six patients. Traumatic arterial occlusion was identified in 22 patients (28.9 percent). Flap failure was seen in five patients and the limb salvage rate was 94.7 percent. All four of the limbs amputated had at least a single artery occluded on preoperative computed tomographic angiography; preoperative arterial occlusion was found to be a significant predictor of limb loss (p < 0.05). CONCLUSIONS: The incidence of single-vessel traumatic arterial occlusion within traumatized lower limbs undergoing free tissue transfer may be as high as 29 percent. Computed tomographic angiography provided excellent visualization of lower extremity vasculature, and its routine use for trauma patients is safe. Flap failure rates were low when using this technique for preoperative planning. Flap failure occurred only in patients with evidence of arterial injury. Evidence of arterial occlusion on computed tomographic angiography may be a risk factor for limb loss.

Early clinical outcomes with the use of decellularized nerve allograft for repair of sensory defects within the hand.

Nerve conduits have become an established option for repair of sensory deficits of up to 2 cm. More recently, decellularized nerve allograft has also been advocated as an option for nerve repair; however, no clinical studies have examined its efficacy for the treatment of sensory nerve defects. The aim of this study was to examine our early experience with the use of decellularized nerve allograft for repair of segmental nerve defects within the hand and fingers. From July 2007 to March 2008, seven patients who had ten nerve gaps were treated surgically using decellularized nerve allograft. Eight digital and two dorsal sensory nerves were repaired. The etiologies of the nerve defects were traumatic nerve transection in eight defects and neuroma resection and reconstruction in two defects. All of the affected nerves were pure sensory fibers. Functional recovery was evaluated by blinded hand therapist using moving and static two point discrimination tests. Implantation sites were also evaluated for any signs of infection, rejection, or graft extrusion. There were five men and two women with a mean age of 44 years (range 23-65). Mean nerve graft length was 2.23 cm with a range of 0.5-3 cm. Mean follow up time was 9 months (range 5-12). Average two point discrimination was 4.4 mm moving and 5.5 mm static at last recorded follow-up. There were no wound infections observed around the graft material and sensory improvement was observed in all of the patients despite this short-term follow-up. Re-exploration of two fingers was required for flexor tendon rupture in one and flexor tendon tenolysis in the other. In both cases, the nerve allograft was visualized and appeared well incorporated in the repair site. Decellularized nerve allografts were capable of returning adequate sensation in nerve defects ranging from 0.5 to 3 cm. There were no cases of infection or rejection. Decellularized nerve allograft may provide an option for segmental nerve gaps beyond 2 cm. Randomized comparative studies will be required to determine efficacy in comparison to collagen conduits or nerve autograft.

[Perioral electrical burn in children: case report]. / Cocuklarda görülen, perioral elektrik yanigi: Olgu sunumu.

Perioral electrical burns are rarely seen household injuries that cause both functional and aesthetic deformities requiring special consideration for reconstruction. The cause is usually a child younger than 3 years old biting an electrical cord. An eleven-month-old girl admitted to the emergency room with perioral electrical burn after biting an electrical cable of a television. Her burn area included 60% of the lower lip, down to the mentum, and including left commissure, distal part of the tongue and the floor of the mouth. On the 8th day following the burn, the burned necrotic tissues separated from the healthy living tissues and a bleeding from the labial artery was observed. To reconstruct the lip defect, an inferior-based nasolabial flap from the lateral side was used. The mucosa of the flap was dissected and advanced to form the lower lip vermillion. With this case presentation, the principles and options for perioral electrical burns are presented.

Reconstruction with galeal frontalis flap of depressed forehead region in progressive hemifacial atrophy.

Parry-Romberg syndrome is characterized by progressive hemifacial atrophy that is the lack of tissue (generally soft tissue and rarely bone and muscle) in the atrophic area of the face. The etiology and the incidence of this pathologic process are uncertain, but it is relatively rare and self-limited. The objective of this study is to present 21-year-old female patient with progressive hemifacial atrophy who was reconstructed with composite galeal frontalis flap. Although many reconstructive methods have been described, reconstruction of both eyebrow deficiency and forehead atrophy with composite galeal frontalis flap was not described before.