Comparison of post-operative outcomes of graft materials used in reconstruction of blow-out fractures.

BACKGROUND: Trauma to the face caused by assault or impact may cause internal orbital fracture. Increased intraorbital pressure without disruption of soft tissue integrity or causing a fracture line in orbital rims or orbital floor fractures described as 'orbital blow-out fracture'. Such fractures have been categorized as 'pure blow-out fractures' in which only the orbital floor is affected, and 'impure blow-out fractures' in which other maxillofacial bones such as zygoma, maxilla and nasoethmoid are also affected. Physical examination reveals periorbital edema and ecchymosis, subconjunctival hemorrhage, limitation of eye globe movements, diplopia, enophthalmos, dystopia, and infraorbital hypoesthesia. Reconstruction of the orbital bony structures is the most important issue to preserve the standard orbital functions and providing an aesthetic view. Although many surgical approaches have been defined in the literature regarding the attitude and timing of treatment, no consensus exists. In literature; many autogenous and alloplastic biomaterials have been recommended to correct orbital bone defects. METHODS: This study aims to compare postoperative outcomes of patients presenting with pure and impure blow-out fractures repaired with cartilage, bone grafts, titanium mesh or porous polyethylene implant. Sixty-four orbital floor fractures of 62 cases were included in this research who admitted to our clinic with maxillofacial trauma between 2011 and 2018. All patients underwent maxillofacial radiological examination; Waters radiography and also axial-coronal plane maxillofacial and orbital computerized tomography. RESULTS: Permanent, post-operative, vertical diplopia in extreme gazes was detected in 3 of 14 patients in whom the orbital floor was reconstructed with an iliac bone graft. Two of nineteen cases who underwent reconstruction using auricular conchal cartilage graft had vertical diplopia in extreme gazes four months after the operation. The implant extruded and became palpable in 2 of 15 patients in the porous polyethylene implant group. None of the patients in the iliac bone and conchal cartilage autograft groups was presented late postoperative enophthalmos according to the graft resorption. In titanium mesh group, 1 of eleven patients had permanent, post-operative vertical diplopia in extreme gazes. None of the patients in this group developed any donor area complications, infection, or implant extrusion. CONCLUSION: Results show that the auricular conchal cartilage graft was the best biomaterial used to repair defects smaller than 4 cm², where as titanium mesh was a good option to repair defects larger than 4 cm². However, selection of the optimal biomaterial to be used to repair orbital blow-out fractures should be made according to patient characteristics and preoperative findings, the severity of the injury, the cost of the biomaterial to be used, and surgeon's expertise.

Comparison of two approaches for carpal tunnel release: Extended versus mini-open technique.

OBJECTIVES: This study aims to describe a retrospective study using prospectively gathered data to compare mini-open and extended open release techniques for moderate to severe carpal tunnel syndrome (CTS). PATIENTS AND METHODS: The data of 198 consecutive patients (139 males, 59 females; mean age 57.0±4.5 years; range, 44 to 75 years) treated for CPS were used. For matching, age, gender and severity of the compression, the Greathouse Ernst Halle Schaffer neurophysiological classification system was used. After matching, 63 observations in each group (group 1: mini-open and group 2: extended open) were used for analysis. A Jamar hydraulic hand dynamometer was used to measure pre- and postoperative third month grip strengths. The key pinch test was performed also at third month. Patients completed the Boston Carpal Tunnel Questionnaire at the last follow-up. RESULTS: Symptom severity and functional status were improved up to half fold in both groups at final follow-up; however, there was no statistically significant clinical difference between the groups (p>0.05). There were totally six patients with paresthesia symptoms (three in each group; 4.7%), which improved in three months. Eight patients (6.3%, one in group 1 and seven in group 2, p=0.032) had dysesthesia and pillar pain. CONCLUSION: Mini-open and extended open carpal tunnel release have similar clinical outcomes without any major complications.

Chronic Boutonniere Deformity: Cross-Lateral Band Technique Using Palmaris Longus Autograft.

PURPOSE: The purpose of this study was to evaluate the outcomes of treatment of chronic boutonniere deformity with a reconstruction technique using palmaris longus autograft. MATERIALS AND METHODS: Seven patients with chronic, posttraumatic, flexible boutonniere deformities referred to our clinic between January 2010 and September 2014 were included in the study. In all 7 patients, the lateral bands were deficient or damaged beyond repair. A novel reconstruction technique for chronic boutonniere deformity utilizing palmaris longus autograft was used. The 2 lateral bands were reconstructed by attaching the palmaris longus tendon grafts from the lateral part of the central slip proximally to the volar aspect of the distal phalanx distally using pull-out sutures. The grafts were positioned so that they crossed over one another at the level of the middle phalanx. The patients were followed for a mean of 14 months (range, 12-16 months). The principal outcome measure was the range of motion of the proximal (PIP) and distal (DIP) interphalangeal joints. RESULTS: Before surgery, the average PIP joint active flexion was 69° (range, 60°-85°). After surgery, the average PIP joint active flexion increased to 92° (range, 90°-100°). Before surgery, the average PIP joint extension deficit was 54° (range, 40°-60°); after surgery, the average deficit was reduced to 7° (range, 5°-15°). Before surgery, the average DIP posture was 9° of hyperextension (range, 5°-12°); after surgery, DIP hyperextension was reduced to 2° (range, 0°-5°). Before surgery, the average DIP active flexion was 40° (range, 35°-55°); after surgery, this increased to 55° (range, 43°-72°). No patients developed a DIP flexion contracture. CONCLUSIONS: In the chronic boutonniere deformity, when the lateral bands are deficient or damaged, our cross-lateral band reconstruction technique using palmaris longus autograft is a treatment option with satisfactory results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Reconstruction of Tissue Defects Developing After Excision of Non-Melanoma Malignant Skin Tumors in Scalp and Forehead Regions.

AIM: The scalp and forehead are the anatomical regions where non-melanoma malignant skin tumors are commonly seen due to direct sun exposure. After surgery for non-melanoma malignant skin tumors located in the scalp and forehead, many complex defects can develop, ranging from sole skin defects to deep defects in which bone and dura mater are opened. MATERIAL AND METHODS: This study examined 43 patients who presented to the Department of Plastic Surgery in Ankara Numune Training and Research Hospital and were diagnosed with non-melanoma malignant tumors of scalp and forehead between 2006 and 2013. The number of operations, the operation techniques applied, the number and type of complications (if any) of free tissue transplantation were also investigated. Various techniques are used for reconstruction of scalp and forehead region following resection of non-melanoma skin tumors. RESULTS: In order to accomplish satisfactory results these patients have to be carefully assessed with specific parameters while performing the reconstruction of the defect and reconstruction should be planned. Patients with local invasion may need adjuvant radiotherapy postoperatively and reconstruction with free flaps is reliable in the prevention of the possible comorbid problems due to radiotherapy. CONCLUSION: Multidisciplinary approach is needed and the treatment should be managed with neurosurgical team, radiation oncologists and medical oncologists.

The effect of recombinant hirudin on rabbit ear flaps with venous insufficiency.

The effect of recombinant hirudin, which is the most powerful antithrombotic agent, on flaps with venous insufficiency was investigated. Oedema and congestion are frequent on flaps, causing necrosis unpredictably. Venous insufficiency and thrombosis are experimentally and clinically more frequent than arterial occlusion. Twenty-one adult New Zealand rabbits were used in this study. Skin flaps (3 × 6 cm) were elevated on a 1-cm-wide pedicle on rabbit ears. The artery, nerve, and vein were exposed and examined with the aid of a surgical microscope. Venous insufficiency was established by cutting the vein and nerve. In the control group, no additional surgical or medical procedures were performed and the ear flap was inset to its original location. Subcutaneous low molecular weight heparin (LMWH; 320 IU/kg) was administered to a second group of rabbits after the same surgery, and recombinant hirudin (2 µg) was administered via the pedicle artery 5 minutes after the vein and nerve were bound and cut in a third group of rabbits. Compared with control and LMWH groups on day 3 and 7, the hirudin-treated group had less hair loss, lower oedema scores and less haematoma formation. Furthermore, a lower size of necrotic areas and an increase in the circulating area on day 7 was found in the hirudin-treated group. In addition, angiography revealed new vessel development (neovascularisation) only in the hirudin group. On histologic sections, hirudin-treated animals had lower oedema, inflammation and congestion scores than animals in the other two groups. Thus, when administered into the ear flap through the pedicle as a pure recombinant preparation, hirudin increased flap survival by its antithrombotic effects and by accelerating neoangiogenesis. Recombinant hirudin may be used in clinical practice to treat flaps with venous problems and to increase survival rates.

A new facial artery free-style perforator flap and conchal cartilage graft for one-step reconstruction of the alar defects.

The nose is the most commonly affected area by basal and squamous skin carcinomas of the head and neck area (D'Arpa et al. J Plast Reconstr Aesthet Surg. 2009, 62:36-42). The nasolabial flap is a very well known local flap that provides excellent color and texture matches. However, its major drawback is that it requires a 2-stage procedure to restore an adequate nasal cheek groove (Karsidag et al. J Craniofac Surg. 2010;21:1887-1889). In the perforator flaps, there are numerous studies that describe flaps whose vascular supply depend on perforators from the fascial artery.We planned to harvest a perforator flap around the medial cheek area, which included one cutaneous perforator from the facial artery. Free-style facial artery perforator flaps and auricular conchal cartilage framework were performed in 9 patients who have alar defect due to malignancies.From September 2010 to December 2011, the free-style facial perforator artery flap was performed in 9 patients at the Plastic and Reconstructive Surgery Department of the Ankara Numune Training and Research Hospital, Turkey. The whole flap was used to reconstruct the whole alar unit, which includes cartilaginous tissues.Our aim is to define a one-stage reconstruction technique with a perforator-based flap. Our flap is supplied by a perforating branch of the facial artery. We develop this method because of its reliable vascularization, that is, the possibility of performing one-stage technique with sensation preservation.In conclusion, we strongly recommend one-stage reconstruction in any kind of alar region defect with this versatile facial perforator flap.

A cutaneous angiosarcoma arising from the rhinophyma.

In this article, we report a 66-year-old male case of rhinophyma who had a persistent lesion on his nose for two-years. Despite steroid therapy, the lesion continued to grow. Histopathological and immunohistochemical findings were consistent with cutaneous angiosarcoma. Rhinophyma-like features should be considered as an unusual clinical manifestation of cutaneous angiosarcoma.

The intraneural hemangioma of the digital nerve: case report.

Intraneural Hemangioma of the digital nerve is rare and so far three cases have been reported in the literature. We present a case of 12- year- old boy with painless soft tissue mass in the right hand and numbness on the radial aspect of the index finger. Magnetic Resonance Imaging showed an isointense subcutaneous lesion without discrete borders in the first web space classically of hemangioma with the radial digital nerve extension. On exploration, the intraneural extension of the hemangioma was confirmed and total resection, microsurgical primary digital nerve repair was done. The patient became better and at 6 months follow up the index finger sensation improved. The patient had no reccurence and he is still under follow up.

Situs inversus totalis with accompanying craniodiaphysial dysplasia: a new syndrome?

A 20-year-old man with craniofacial anomalies of craniodiaphysial dysplasia (CDD), facial paralysis, mental retardation, and situs inversus totalis is described. Similar features except situs inversus totalis are also present in two of his sisters. The authors believe this to be the first reported case of CDD with accompanying situs inversus totalis.