Reconstruction of Multiple Lip and Facial Defects With Bipaddle and Sensate Radial Forearm Free Flap.

ABSTRACT: Free flaps and their modifications are used to reconstruct multiple large defects in the lip and face. In this study, we present our results on the reconstruction of these defects using bipaddle and sensate free radial forearm-palmaris longus flaps and subsequent revision surgeries. Patient medical records of 11 patients with a mean age of 63.9 ± 12.8 years were retrospectively reviewed. Functional oral competence, lip cosmetics, lip sensation, and donor forearm scars were evaluated using the drooling rating scale, visual analog scale, Semmes Weinstein Monofilament test, and patient and observer scar assessment scale, respectively. The mean dimensions of distal and proximal skin paddles of bipaddle free radial forearm-palmaris longus flaps were 12.7 ± 9.9 and 20.5 ± 3.8 cm2. Mean lengths of the bridge and proximal pedicles were 4.7 ± 1.6 and 5.5 ± 0.7 cm. All the flaps survived. No drooling was observed in the 2 patients without lower lip defects. The mean drooling scores of the 9 patients with lower lip defects were statistically different (Analysis of Variance, pANOVA < 0.00001) at 3, 6, 9, and 12 months postoperatively. The differences between 3 and 12 months were the most significant (pANOVA < 0.00001, pTUKEY < 0.000001). The lip sensation and drooling scores showed a strong positive correlation (r = 0.8504). All patients were able to speak fluently, drink fluid without leakage, and blow a balloon easily. All patients and observers were satisfied with the lip cosmetics, with no significant difference between satisfaction scores (P = 0.087615).There was a statistically significant difference (P < 0.00001) between mean sensation scores of surrounding healthy lip (2.94 ± 0.27) and free flaps (4.15 ± 0.4). All the donor scars healed uneventfully.

Perforation With Submucosal Cleft Palate in a Previously Undiagnosed Adult Patient.

Perforation with a submucosal cleft palate (SMCP) is a rare condition with a limited number of cases reported in the literature. However, most described cases include neonates and infants, but not cases due to trauma or infection. Here, we present a case of an adult patient with SMCP with a perforation of the palate who was undiagnosed. In light of this case, diagnosis and treatment of perforation in SMCP are presented. A new diagram that can be used in the management of these patients with velopharyngeal insufficiency is proposed.

V-Y and rectangular flap combination for syndactyly repair.

OBJECTIVE: For syndactyly repair, several delicate, well-planned flap combination techniques have been reported. This study presents technique details with functional and aesthetic results of a dorsal rectangular and volar V-Y advancement flap combination for web reconstruction and S incisions for finger separation in patients with syndactyly. METHOD: Ten patients with 16 syndactyly webs were treated. Patients were examined in terms of function and aesthetic. Evaluation criteria included the Vancouver Scar Scale, range of motion, degree of web creeping, parent's satisfaction rates, and finger abduction. During the initial period, vascular compromise of fingers, haematoma, infection, seroma, flap necrosis, or graft failures were not noted in any patients. No patients required revision surgery. During the later period, parent satisfaction scores were excellent or good, finger function was complete, and the Vancouver Scar Scale showed that two webs had hyperpigmented areas and two had supple pliability. CONCLUSION: This simple syndactyly release technique can provide a low rate of web creep, good scar quality, and optimal functional results.

Analysis of unilateral complex orbital fractures with a new treatment algorithm.

The aim of this study is to investigate preoperative and postoperative properties, the management of unilateral complex orbital fractures, and to offer an algorithm for orbital fractures. For this research study, 248 patients with orbital trauma were evaluated according to an offered algorithm. Diplopia, enophthalmos, dystopia, infraorbital nerve dysfunction, and ocular movement limitations were documented for clinical assessment. Orbital rim displacement and an orbital volume check with computed tomography (CT) were used for indication of surgery. The injured orbital volume was compared with the healthy orbital volume in the preoperative and postoperative periods. In total, 58 patients required operations among the 248 patients, according to the algorithm. The preoperative mean injured orbital volume measurements of the operated patients were statistically different than the healthy orbital volume measurements (30.13 cm3 ± 2.69 cm3 and 27.15 cm3 ± 1.29 cm3, respectively). In the postoperative period, there was no difference between the injured and healthy orbital volume. In conclusion, an algorithm may facilitate the approach to unilateral complex orbital fractures. Ophthalmic examination, rim displacement, and the measurement of orbital volume using computed tomography are key points of orbital fractures with regard to management.

The worth of sound recording as evaluation criteria of response to surgery in non-reduced anterior disc dislocation.

AIM: The objective of the present study was to examine whether joint sounds are objective criteria for evaluating the success of surgery for non-reduced anterior disc dislocation. METHOD: Twenty-seven patients (age, 35.6 ± 10.6 years; female/male, 22:5) with non-reduced disc dislocation, as confirmed by MRI, were included in the study. Temporomandibular joint (TMJ) sounds were assessed and digitized by custom-made device. As a surgical treatment, all patients underwent "disc plication technique". The success of surgery was evaluated with maximal interincisial opening (MIO), pain, patient satisfaction scores, MRI examination, and TMJ sound intensity. Recording of sounds of TMJ and pain and satisfaction scores were repeated again at postoperative 12 months and compared to preoperative results. RESULTS: Mean preoperative sound intensities with jaw opening and closing and left-right movement were 79.37 ± 3.52 dB and 81.0 ± 4.99 dB, respectively. Mean postoperative sound intensity with jaw opening and closing was 64.81 ± 4.54 dB whereas that with left-right movement was 65.6 ± 5.38 dB. Examination of preoperative and postoperative sounds showed that decreased volume level related with clinical improvement and postoperative replaced disc image in MRI. MIO values increased from 25.89 ± 1.76 mm to 34.26 ± 1.403 mm. Postoperative pain scores were lower than preoperative period and patient satisfaction improved markedly. CONCLUSION: The results of this study showed that patients who underwent plication for non-reduced disc dislocation had clinical improvement, which was related with the decreasing volume level of the click sound, reducing the pain, improving satisfaction, and replacing the disc to normal position in MRI.

Comparison of bone dust with other types of bone grafts for cranioplasty.

PURPOSE: Split calvarial bone graft is preferred in the reconstruction of calvarial defects. However, it is not feasible for use in some challenging cases and in children. Particulate bone graft containing viable osteoblasts could be an attractive alternative. MATERIALS AND METHODS: A total of 32 female rats were randomly separated into 4 groups. Full-thickness bone graft from rat calvaria was harvested in diameters of 8 × 8 mm. In group 1, the periosteum and skin were closed without any bone graft; bone dust particles were placed in group 2; bone fragments were placed in group 3; and full-thickness cranial bone graft was placed in group 4. After 12 weeks, all rats were killed. Degrees of resorption, foreign body reaction, and bone spicule length were assessed histologically, and an immunohistochemical study was used to show bone graft viability. RESULTS: In graft viability, osteogenesis, and osteoblastic differentiation, groups 3 and 4 were similar and superior to groups 1 and 2. No osteoblastic activity and no viable bone dust were detected in groups 1 and 2. Resorption was observed in every preparate that contains bone tissue, and foreign body reaction was prominent in small bone groups, such as in group 2. CONCLUSIONS: In the full-thickness cranial bone graft group and the bone fragment group, the preservation of bone viability was obviously superior to the bone dust group and the periosteum-only group. In conclusion, bone dust behaved like the periosteum and could not create new bone, whereas bone particles behaved like the full-thickness cranial bone graft and were capable of preserving viability.

Is it necrotizing fasciitis or necrotizing cellulitis after varicella zoster infection? Two case reports.

Necrotizing fasciitis and necrotizing cellulitis are serious cutaneous complications in varicella patients. Differentiation of necrotizing cellulitis from necrotizing fasciitis can initially be challenging because of indistinct clinical course at the onset of infection and the lack of definitive diagnostic criteria. This paper reports 2 children with necrotizing cellulitis that developed after varicella infection to draw the attention of health care providers to necrotizing cellulitis that showed slower clinical course than necrotizing fasciitis and recovered with conservative treatment approaches without aggressive surgical intervention.

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.

Combined use of ultrasound guided infraclavicular block and lateral femoral cutaneous nerve block in upper extremity reconstruction requiring large skin graft: case report.

Combined nerve blocks of the upper extremity and lower limb in same operation rarely performed due to the risk of systemic toxicity of local anesthetics. Therefore, general anesthesia is generally preferred in this operations. However, use of ultrasound allows reliable deposition of the anesthetic around the nerves, potentially lowering the local anesthetic requirement. In this case report, we present a 44-year-old, ASA physical status I, male patient who was operated for upper extremity reconstruction requiring skin graft from anterolateral thigh region under ultrasound-guided infraclavicular brachial plexus block and lateral femoral cutaneous nerve block. The block was successful and no block-related complications were noted. We think that combining an ultrasound guided infraclavicular brachial plexus block and a lateral femoral cutaneous nerve block is a clinically useful and safe technique and an alternative anesthetic method for procedures requiring skin grafts for the upper extremity.