Functional reconstruction of the lateral face after ablative tumor resection: use of free muscle and musculocutaneous flaps.

BACKGROUND: Wide resection of tumors of the middle third of the face often results in complex three-dimensional defects and facial paralysis either due to removal of the facial nerve within the tumoral tissue or to extensive resection of the facial muscles. METHODS: We report the cases of three patients who underwent wide excision of tumors of the cheek region, operations that resulted in tissue defects and facial palsy. Defect reconstruction and facial reanimation was accomplished in one stage through functional muscle transplantation. RESULTS: Follow-up of more than 1 year showed good symmetry at rest and reanimation of the corner of the mouth in all cases, but one patient, in which the ipsilateral facial main trunk was used as motor nerve supply to the transplanted muscle, developed significant muscle contracture and binding of the cheek skin. CONCLUSIONS: Every effort should be made to optimize the functional and cosmetic outcomes of neurovascular muscle transfers through precise planning and careful execution of the intricate details of the surgical technique for muscle transplantation.

Reliability of island flaps raised after superficial and deep burn injury.

In select cases, to prevent any functional loss and to initiate early function during the early burn period, the reconstructive procedure of choice may be flap coverage. In these circumstances, when the ideal flap donor site is burned, the clinician may be hesitant to raise this flap because of questionable flap survival. The authors conducted this study to determine whether a superficially or deeply burned skin island flap would survive when elevated during the early postburn period. If these flaps are usable, they could expand the options available for burn wound coverage. They used a rat epigastric island flap model, and divided 50 study animals into two groups. In group 1 (N = 25), the right epigastric flap site was burned superficially and the left side was left uninjured. Island flaps were raised on both sides 4 days after the burn injury. The flaps were then sutured back into their original sites, and were evaluated 5 days after the surgery. In group 2 (N = 25), the right epigastric flap site was burned deeply and the left side was left uninjured. Island flaps were raised 4 days after the burn injury on both sides, as in group 1. The flaps were then sutured back into place and were evaluated 5 days after the surgery. All of the control flaps on the rats' left sides survived in both groups. In addition, all the superficially burned flaps survived in group 1 (100%), and 21 of the deeply burned flaps survived in group 2 (84%). There was no significant difference between superficially and deeply burned flaps with regard to survival, and the burned flaps were as successful as the unburned control flaps in both groups (p = 0.11). Skin island flaps elevated after superficial or deep burn injury are reliable in this animal model.

Fingertip reconstruction using two variations of direct-flow homodigital neurovascular island flaps.

The fingertip is an extremely intricate area of digital sensibility that plays an important role in fine perception and hand function. Thus, sensate fingertip reconstruction is essential to the recovery of most hand functions. The authors used two methods of direct-flow homodigital neurovascular island flap coverage to reconstruct distal finger amputations-namely, the triangular-advancement flap technique and the step-advancement flap method. The authors present their experience with these two variations of direct-flow homodigital neurovascular island flaps and their use in reconstructing 18 fingertips and 7 proximal amputation stumps. They did not observe flap failure, and they achieved stable, well-vascularized, appropriate-thickness skin coverage with good sensory properties in all patients. However, they found that the triangular-advancement flap technique was easier to plan and perform than the step-advancement method.

The Koebner phenomenon in immunosuppression-related Kaposi's sarcoma.

The Koebner phenomenon has been reported to develop in classic or acquired immune deficiency syndrome-related Kaposi's sarcoma (KS). A 12-year-old kidney transplant recipient who developed immunosuppression-related KS showed reoccurrence of lesions in some previously intact incision sites following removal of tumor, suggesting Koebner phenomenon. It is recommended that surgeons be careful when planning surgical interventions in patients with certain skin disorders in which Koebner phenomenon is known to develop.

Reconstruction of the upper portion of the ear by using an ascending helix free flap from the opposite ear.

Reconstruction of partial, marginal defects of the ear has been a challenge. The ascending helix free flap based on superficial temporal vessels has been described and used solely to repair nose defects. We used reversed pedicle helical free flap for the repair of a major loss of the upper one-third of the opposite auricle. The method permits the transfer of tissue of the same quality with satisfactory cosmetic result. The equalization of the ears in dimension was accomplished with minimal donor-site deformity.

An unusual hand injury caused by powered woodsplitter--split fingers.

We present a case of very unusual injury to the right hand of a 14-year-old boy who had an accident with a powered woodsplitter. The trauma produced a unique hand injury pattern. All fingers except the thumb were split into dorsal and volar sections without any bone fractures, mimicking surgically elevated volar flaps. We achieved satisfactory hand function using simple surgical and conservative management in this unique hand injury case.

Effectiveness of human amnion preserved long-term in glycerol as a temporary biological dressing.

Human amnion as a temporary biological wound dressing has remained a beneficial and cost-effective means of treating burns in developing countries. The aim of this study was to determine whether human amnion that has undergone long-term preservation in glycerol is an effective biological dressing compared to fresh amnion and glycerol-preserved human skin. Samples of human amnion and skin were preserved in sterile containers of 85% glycerol at 4 degrees C for over a year. Dorsal full-thickness or split-thickness skin wounds were produced in rats. The defects were divided into four areas, each of which was covered with preserved amnion, fresh amnion, preserved skin, or left uncovered as a control. The materials on the wounds were evaluated macroscopically and microscopically after 2, 4, 7, 10 and 14 days. The primary take or adherence of the grafts on full-thickness wounds was evaluated at 4 and 7 days, and material performance was scored based on several macroscopic and microscopic criteria. The bacteria levels reducing effect of the materials were examined by quantitative bacteriology in heavily infected full-thickness scald burn wounds of rats. Qualitative cultures confirmed that the storage conditions the materials were subjected to for over a year were aseptic and that the amnion and skin had maintained their characteristic properties. All materials were found effective on partial-thickness rat wounds as a cover under which re-epithelialization was completed by 7 days. The preserved skin performed better than either preserved or fresh amnion on full-thickness wounds but the performance of preserved amnion was comparable to that of fresh amnion. Glycerol-preserved amnion was found to be as effective as fresh amnion or skin in terms of decreasing bacterial levels in infected rat burn wounds. Amnion stored in glycerol is reliable and effective for a long period of time. Amnion banking could provide an unlimited quantity of biologic dressing for burn treatment at low cost, a factor that is particularly important in developing countries.

Skin flap survival after superficial and deep partial-thickness burn injury.

Whether a flap can be raised successfully in a body region that has been subjected to burn injury remains an issue. The aim of this study was to investigate the survival of skin flaps that were elevated after superficial and deep partial-thickness burn injury in a rat model. Sixty-five rats were divided into five groups: Group 1 (N = 15) was the control group, group 2 (N = 10) included rats with superficial partial-thickness burns that had flaps elevated on day 0, group 3 (N = 15) was comprised up of rats with superficial partial-thickness burns that had flaps elevated on day 4, group 4 (N = 10) included rats with deep partial-thickness burns that had flaps elevated on day 0, and group 5 (N = 15) was comprised of rats with deep partial-thickness burns that had flaps elevated on day 4. Caudally based dorsal flaps consisting of skin and panniculus carnosus were elevated in all groups, and the amount of surviving tissue on each flap was quantified. The surviving areas of flaps elevated on postburn days 0 and 4 in superficial partial-thickness burn zones (groups 2 and 3) were larger than those of flaps that were elevated on postburn days 0 and 4 in deep partial-thickness burn zones (groups 4 and 5). The surviving portions of flaps that were elevated on day 4 in superficial partial-thickness burn zones (group 3) were similar to the surviving areas of flaps in the control group (group 1), and were larger than those of all other groups (groups 2, 4, and 5). In this rat model, flaps were elevated in superficial dermal burn zones with successful outcomes. However, raising flaps in deep dermal burn zones was not a reliable method.

A case of popliteal pterygium treated along with nerve expansion.

The presence of a short sciatic nerve in the free edge of a popliteal pterygium makes this syndrome a surgical challenge. We present a case of popliteal pterygium that was treated by nerve expansion. The range of motion of the patient's knee joint was between 30 and 120 degrees. A 75-cc tissue expander was placed under the sciatic nerve and filled with 5 cc of saline solution weekly. When a total of 60 cc was reached, wound dehiscence was observed, and the procedure had to be stopped. The maximum extension obtained was 160 degrees. Since the expansion process had to be stopped early, the elongation attained by expansion was less than expected. We conclude that the nerve expansion method can be used as a good alternative treatment modality for patients with popliteal pterygium.

A technique for the repair of simple congenital earlobe clefts.

Congenital cleft of the earlobes is rarely seen among congenital ear anomalies. These clefts show a wide range of severity and localization, from simple notching to extensive tissue deficiencies. We developed a new technique that can be used in simple cases of earlobe cleft. For this technique, we use the anterior and posterior parts of the cleft as Y-V advancement flaps and achieve a three-dimensional construction of the lobe that is symmetrical with the opposite lobe.

A case of bilateral anomalous origin for dorsalis pedis arteries (anomalous dorsalis pedis arteries).

A case of bilateral anomalous arterial supply of the lower limb is presented. In this case, both anterior tibial arteries were hypoplastic. These arteries came to the anterior (extensor) compartment by passing superiorly through the interosseous membrane. They ran between the tibialis anterior and the extensor hallucis longus muscles and terminated after giving numerous muscular and fascial branches. The dorsalis pedis arteries originated from the peroneal arteries. The peroneal arteries reached the anterior compartment by piercing the interosseous membrane at its lower part and ran as the dorsalis pedis arteries. Awareness of the anatomical variations in anatomy of the distal popliteal artery is important for angiographers, vascular surgeons and reconstructive surgeons who operate upon these regions.