Comparison of The Thickness of Free Anterolateral Thigh Flap in Different Fascial Planes: Clinical Results of Subfascial and Superficial Fat Flap.

Background The anterolateral thigh (ALT) flap is a preferred option in the reconstruction of a wide variety of defects, enabling multiple tissue components and thicknesses. Methods This study was conducted to investigate the correlation of the thickness of the traditional subfascial ALT flap and superficial fat flap with age, gender, and body mass index (BMI). A total of 42 patients (28 males and 14 females) were included in the study. Results Mean age was 50.2 (range, 16-75) years and mean BMI was 24.68 ± 4.02 (range, 16.5-34.7) kg/m 2 . The subfascial flap thickness was significantly thinner in male patients (16.07 ± 2.77 mm) than in female patients (24.07 ± 3.93 mm; p < 0.05), whereas no significant difference was found between male (4.28 ± 1.15 mm) and female patients (4.85 ± 1.09 mm) regarding superficial fat flap thickness ( p = 0.13). The thickness of both flaps had a positive correlation with BMI, and the strongest correlation was found for subfascial ALT thickness in female patients ( r = 0.81). Age had no effect on both flap thickness measurements. The anterior thigh is thicker in women than in men, although it varies according to BMI. This shows that flap elevation is important in the superthin plane, especially if a thin flap is desired in female patients in defect reconstruction with the ALT flap. Thus, a single-stage reconstruction is achieved without the need for a defatting procedure after subfascial dissection or a second defatting procedure 3 to 6 months later. Conclusion The appropriate ALT flap plane should be selected considering the gender and BMI of the patient.

New Approach for Superthin Anterolateral Thigh Flap Elevation.

BACKGROUND: Anterolateral thigh (ALT) flaps are widely used for soft tissue reconstructions. They have several advantages, most notably a long pedicle, an appropriate pedicle caliber, low donor site morbidity, and the possibility of 2 teams working simultaneously. However, conventional, thick ALT flaps used for reconstructions of head and neck and lower extremity defects may cause postoperative range of motion limitations and cosmetic problems. The aim of this study was to develop and propose strategies to facilitate the harvest of superthin ALT flaps and minimize technical difficulties. This article provides step-by-step instructions for simple, quick, and reliable dissections of superthin ALT flaps. METHODS: This study retrospectively analyzed data from 60 free superthin ALT flaps used for soft tissue reconstructions in 56 patients between January 2018 and February 2019. Superthin flaps were elevated just above the superficial Scarpa's fascia using a vertical approach. RESULTS: Thirty-eight of the patients were operated on for lower extremity wounds, 16 were for head and neck defects, and 6 were for upper extremity wounds. The mean follow-up period was 7 months. The median hospital stay was 10 days. Total flap loss was observed in 4 cases (6.6%), and partial flap loss was observed in another 4 cases (6.6%). CONCLUSIONS: The superthin elevated ALT flap is a reliable and effective option for the reconstruction of soft tissue defects. In our vertical approach, the wide field of view of the flap perforator provides easy dissection, making it easier to elevate the superthin ALT flap.

The evaluation of the effect of free gracilis muscle transfer on cheek tone and oral competence in long-standing facial paralysis of patients by using Blasco index.

PURPOSE: Smile and eyelid reanimation are generally emphasized in facial reanimation, but the loss of cheek tone provided by the buccinator muscle is not adequately addressed. The use of free gracilis muscle flap for facial reanimation has become widespread since it was used in head and neck reconstruction by Harii et al. The effect of free gracilis muscle transfer on drooling is not clearly defined in the literature. In our study, we aimed to evaluate the effect of free gracilis muscle transfer on drooling in patients with facial paralysis (FP) by using Blasco index. Smile function was overemphasized in the literature, but drooling was not evaluated. What happens to drooling after free functional muscle transfer was not clear, so this study was designed to evaluate improvement in drooling. PATIENTS AND METHODS: Drooling and smile were evaluated in 11 patients (4 male, 7 female) who underwent facial reanimation with a free functional gracilis muscle transfer (FFGMT), in long-standing FP. The mean age was 39.9 years (range 22-56 years). Etiology was idiopathic in two patients, trauma in five patients, and intracranial tumor in four patients. Photographs and video recordings were taken preoperatively and at the first year postoperatively. The muscle was stitched to the upper lip, corner of the mouth, lower lip and the preauricular region. Masseteric nerve was preferred as donor nerve. Smile restoration was evaluated according to the five-stage classification defined by Terzis and Noah. RESULTS: Flap dimensions differed from 12 cm× 5 cm to 15 cm× 6 cm. Oral intake was stopped for 5 days, and speaking was restricted postoperatively. Patients exercised for about 1 h starting from the postoperative third month. Patients were followed up for an average of 26.5 (14-48) months postoperatively. Postop courses were uneventful, and we did not observe any complications in these patients. Preoperative Blasco index score was 3 in 6 patients, 2 in 5 patients and the mean scores were 2.54 ± 0.52. Patients were followed for 1 year. No drooling was observed in the postoperative first year. The Blasco index score was 0 for all patients. The decrease in postoperative scores was found to be statistically significant (p < .01). Smile restoration was evaluated according to the five-stage classification defined by Terzis and Noah for facial reanimation after muscle transfer. Excellent results (grade 5) were obtained in 6 patients, good results (grade 4) in 4 patients and moderate results (grade 3) in 1 patient. CONCLUSION: Free functional gracilis muscle transfer improves chewing functions and prevents drooling. This case series reveals that FFGMT can be a good option to enable cheek tone in long-standing FP of patients.

Reconstruction of burn contractures with free anterolateral thigh flap in various anatomic sites.

BACKGROUND: Burn contractures that cause a restriction in extremity movements have to be reconstructed. Free microvascular flaps are generally needed in cases of severe contractures. The ideal free flap for severe contracture defects has to have a large skin island without bulk and a long pedicle for preventing recurrence and tension-free adaptation. Anterolateral thigh flap (ALT flap) that meets these features has widely been used for several indications in reconstructive surgery. Usage of ALT flap in burn contracture was described for burn and axillary contractures in literature. In this study, the usage of free ALT flaps in various anatomic contracture sites was reported. METHODS: Fifteen free ALT flaps were performed in 14 (12 male, two female) patients with a mean age of 36.6. Burn contracture defects in neck, axilla, popliteal, cubital region, plantar foot and hand were reconstructed with ALT flap. RESULTS: No total flap loss was encountered. Distal flap necrosis was seen in one case. All patients had significant improvement in a range of motions. Recurrence in contracture was seen in one patient with hand flexor contracture due to lack of physical treatment. CONCLUSION: ALT flap can safely be used in various anatomic contracture sites. Suprafascial elevation of the flap can be preferred for better adaptation in the neck, hand and foot and prevention of bulky appearance.

Total nasal reconstruction with pre-laminated, super-thin anterolateral thigh flap: A case report.

Many techniques for nasal reconstruction have been described to achieve aesthetically and functionally favorable results. Local tissues, specifically the forehead flap, provide the best tissue match with the nose. However, when local tissue donor sites are limited, alternative options such as free tissue transfers should be considered. Herein, we describe a case of a 72-year-old male patient who had a total nasal and left malar defect reconstructed with a two-staged, pre-laminated, super-thin anterolateral thigh (ALT) flap. The patient's nasectomy was performed 15 years ago. The adjacent left malar defect was due to recent squamous cell carcinoma excision. Local tissues were unavailable for reconstruction due to previous tumor excisions. For the 8.5 × 5 cm defect, a 12.5 × 8 cm ALT flap was planned, with 7.5 × 8 cm for nasal reconstruction and 5 × 4 cm for malar reconstruction. During the first stage, a super-thin fascial ALT flap was raised without dissecting the perforators, and the nasal skeleton was laminated between these two flaps. Costal cartilages were harvested for the nasal skeleton and positioned between the suprafascial and the fascial ALT flaps. During the second stage, two perforators were dissected to the pedicle on the pre-laminated flap, and the flap was divided from the donor site. The nasal skeleton was fixed and anastomosis with the facial vessels was established. After both stages, no complications were observed. After one month, a revision surgery was performed to enhance the transition between the reconstructed nose and the cheek, and improve the nasal projection. Postoperatively, after one year, the patient had a stable nasal reconstruction with good breathing. Prelaminated, super-thin ALT flaps provide the advantages of a wide and versatile donor site and an acceptable donor site scar. They may be an option for patients who are not amenable to traditional reconstruction methods.

Reconstruction of lower lip defects with free super-thin anterolateral thigh flap.

BACKGROUND: Lower lip is a vital organ with important functions as well as aesthetic importance. It is critical to provide an aesthetically appealing lower facial subunit with maintenance of understandable speech and oral competence. Achieving these targets is very difficult especially in total lower lip defects. This report presents a technique using super-thin anterolateral thigh (ALT) flaps with fascia graft for reconstruction of large, complex oral sphincter defects. PATIENTS AND METHODS: Six patients with squamous cell carcinoma (SCC) and one patient with a gunshot injury were presented in this report. All of them had full-thickness defects including skin, orbicularis muscle and oral mucosa. The mean age was 58 (range, 32-85) years. Defects of the lower lip were reconstructed with a super-thin ALT flap. Super-thin flaps were obtained by planning as close to the knee as possible and elevating at the level of superficial fascia. The fascia graft was used for achieving lip suspension. RESULTS: Overall flap survival was 100%. The flap size ranged from 8 × 6 cm to 14 × 10 cm. The follow-up periods ranged from 6 to 14 months. All the patients achieved acceptable oral competence, both in the resting condition and during speaking and eating, except for one patient who had a drooping lower lip developed in the post-operative 3rd month and underwent a secondary tightening procedure. Another patient needed liposuction due to bulky appearance. CONCLUSION: Super-thin ALT flaps seem to be a useful option for functional and aesthetic reconstruction of extensive lip defects.

Effects of oxidative stress and apoptosis on vascularity and viability of perforator flaps.

We investigated lateral thoracic and posterior thigh perforator flaps for viability, vascularization, perfusion and apoptosis in a rat model. Wistar albino rats were divided into six groups: lateral thoracic artery perforator flap (LTPF) sham, 3 × 2 cm2 LTPF, 3 × 6 cm2 LTPF, posterior thigh perforator flap (PTPF) sham, 3 × 2 cm2 PTPF, and 3 × 6 cm2 PTPF. Flap viability was determined on postoperative days 1 and 7. On day 7, flaps were photographed and their viability was measured using two-dimensional planimeter paper. Tissue samples were harvested for examination by histology and immunohistochemistry. Viability differences were statistically significant. Epithelial thickness, vascularity and number of fibroblasts were reduced in the 3 × 6 cm2 groups. Neovascularization and apoptosis based on molecular tests were not significantly different among groups. Flap size and location are important factors for closure of surgical or traumatic defects. We suggest that for clinical application, wound complications will occur less frequently with perforators that nourish large areas of flaps.

Preserving the Blood Flow of the Recipient Artery in Cross-Leg Free Flap Procedure for Lower Extremity Reconstruction.

When there is no suitable vessel in the injured leg for microsurgical transfer, cross-leg free flaps can be considered for lower extremity reconstruction. This report describes patients who experienced lower extremity trauma and underwent reconstruction with cross-leg free flaps with preserved blood flow in the recipient artery. Anterolateral thigh flap is preferred for small to moderate defects. The descending branch of the lateral femoral circumflex artery was dissected 2 cm proximally and distally and was prepared in a T-shape. The branches of the T were anastomosed to the recipient artery in the contralateral leg in the first session of the cross-leg free flap procedure. After 3 weeks, the flap artery was separated from the bifurcation. For large defects, the latissimus dorsi flap was chosen. The thoracodorsal artery was anastomosed to the contralateral posterior tibial artery in the first session. After 3 weeks, to provide recipient vessel integrity, the thoracodorsal artery was transected from the flap and anastomosed to the distal stump of the posterior tibial artery. Between January 2017 and January 2019, 8 defects were reconstructed using an anterolateral thigh flap; the remaining 4 defects were reconstructed using a latissimus dorsi flap. All flaps survived without complications. Anterograde flow distal to the anastomosis was confirmed in all recipient arteries via Doppler ultrasound. In cross-leg free flaps, the continuity of the recipient artery can be established to prevent diminished blood flow to the recipient extremity.

Angular artery island flap for eyelid defect reconstruction.

Eyelid reconstruction is a challenging surgical procedure because of the special function and structure of the eyelids. There are various useful techniques which can be used to reconstruct eyelid defects. In this report, the authors aimed to present the clinical results of angular artery-based island flap for the repair of the full thickness eyelid defects. This presented series consists of eight patients with full-thickness eyelid defects. Oncologic resection was the reason for all of them. Five of the patients had lower eyelid defects and the other three had upper eyelid defects. Nasojugal angular artery-based axial flap was used in reconstruction in all patients. The inferior limit of the flap was the alar rim level in order to make the flap totally axial. A tunnel was created under the orbicularis oculi muscle in cases where the medial portion of the eyelids was left intact and healthy. Septal chondromucosal graft was used to repair posterior lamella of the eyelid. The follow-up period of the cases was from 12 months to 22 months, with a mean follow-up period of 16 months. There was only one patient with reconstructed upper eyelid needed flap defatting. There was no ectropion or wound healing problem observed during the follow-up period. This presented series shows that angular artery-based axial flap and septal chondromucosal graft combination is a simple and safe technique for both upper and lower eyelid full-thickness defect reconstruction. The donor site of this flap heals with an inconspicuous scar concealed in the nasojugal area.

An effective technique for managing vascular diameter discrepancies in microsurgery: tapering with a hemoclip.

Microvascular anastomosis is mandatory for free flap surgery, but free flap transfer can be challenging because of vascular diameter discrepancies during microsurgery. Different methods have been described for preventing vascular discrepancies. The aim of this study was to test a simple technique using a hemostatic clip to taper the vessels. In 12 patients who had free tissue transfer with diameter discrepancies between donor and recipient vessels, tapering with a hemostatic clip technique was used. After key sutures were placed on the vessels, a hemostatic clip was placed in an oblique fashion on the vessel with a larger diameter. After the vessel was tapered and the same diameters in the donor and recipient vessels were achieved, anastomosis was completed. This technique was used in head and neck reconstruction and lower extremity reconstruction. The luminal diameters of arteries, and veins of the flap and recipient differed by 1.6- to 3.0-fold and 1.5- to 2.6-fold, respectively. All the flaps survived without complications. Tapering with a hemoclip technique is a rapid procedure that can be considered for managing vascular diameter discrepancies in free tissue transfers.

Anterolateral Thigh Flap Design by Using Suprafascial Course of the Perforator.

OBJECTIVES: Recently, anterolateral thigh flap has become one of the most commonly used free flaps in reconstructive surgery. Although its pedicle has relatively sufficient length, it falls short in some circumstances. Eccentric perforator location can be used to lengthen the pedicle, but flap tip viability can be a problem in this case. In addition, partial flap loss can be encountered in perforator flaps. The aim of this study was the use of multidetector computed tomographic angiography in preoperative mapping to overcome these problems. MATERIALS AND METHODS: Anterolateral thigh perforator flap was planned for various soft-tissue reconstructions in 19 patients. There were 15 males and 4 female patients with ages ranging from 19 to 65 years. These patients were evaluated with preoperative multidetector computed tomographic angiography to choose and to trace the course of the perforators. Flaps were designed according to the suprafascial course of the perforators. Perforators were safely located eccentrically when needed. Pedicle length and complications, such as infection, wound dehiscence, and partial or total flap loss, were recorded. RESULTS: Perforators were located eccentrically in 8 patients and centrally in the other 11 patients. Eleven flaps were used in lower leg reconstruction, 2 flaps in popliteal region, and 6 flaps in head and neck. All flaps survived and any partial or total loss did not occur. There was not any infection and wound problem. CONCLUSIONS: Multidetector computed tomographic angiography can reveal the suprafascial course of the perforator and help design anterolateral thigh perforator flap. By using this kind of mapping, perforators can be safely located eccentrically to lengthen the pedicle and partial flap loss can be prevented.

Clinicopathological characteristics and mutation profile of BRAF and NRAS mutation in cutaneous melanomas in the Western Turkish population

Background/aim: Malignant melanoma is the most common cause of death due to skin cancers. The most common mutations in RAFRAS pathway from tumor oncogenes are BRAF and NRAS. In this study, we analyzed the frequency of BRAF and NRAS gene mutations and investigated their association with clinicopathological features of melanomas in the Turkish population. Materials and methods: 65 primary cutaneous melanoma were included in the study. The mutations were evaluated with real-time PCRbased PCR-array through allele-specific amplification, and the results were correlated with various clinicopathological characteristics. Results: 52.3% of the patients were female and 47.7% were male. The mean age of the patients with a mutation was lower than those without mutation. 16 patients had BRAF mutation. 12 patients had NRAS mutation. NRAS mutation was statistically more common in men (P = 0.036). The number of mitoses increased with the increase of the tumor thickness (P = 0.003). There was more mitosis in the presence of ulceration (P = 0.05). A total of 41.7% of NRAS mutations had adjuvant chemotherapy. Conclusion: We found lower mutation rate when compared to regional studies. NRAS mutation was common in men. This is the first study from our region evaluating the prognostic value of clinical stage and necessity of adjuvant treatment with the presence of BRAF and NRAS mutations.

Modified Temporalis Muscle Flap for Eyelid Reanimation.

The reanimation of both upper and lower paralytic eyelids requires dynamic procedures for longevity of correction. Temporalis muscle ensures the criteria for reanimation and is used widely as a result. Many modifications were described to improve the success of the classical technique. One of these modifications was reported by the senior author in 1999. Twice as much muscle mass (in thickness) to the upper eyelid than the lower was taken and passed submuscularly 5 to 6 mm away from the limbus and a thinner split was passed subcutaneously beneath the lower cilia. The aim of this study was to present the outcomes of the technique after 38 operations with 37 patients and to describe deep temporalis musculofascial-fatty flap to recover depression of temporalis muscle split donor area. Seventeen lower eyelids were evaluated as mild, 12 were as moderate, and 9 were as severe ectropion. One upper eyelid was evaluated as mild, 14 were as moderate, and 23 were as severe lagophthalmos preoperatively. Mean follow-up time was 28.8 months. Five patients had mild ectropion and 2 patients had mild lagophthalmos postoperatively at last follow-up. Two patients needed medial canthal tendon reinsertion secondary to relaxation of fixation suture at medial canthus. All patients tolerated the procedure and all complaints were resolved without creating a notable cosmetic deformity.

Malignant tumor of outer root sheath epithelium, trichilemmal carcinoma. Clinical presentations, treatments and outcomes.

OBJECTIVES: To emphasize different clinical features of tumor that can be misdiagnosed clinically. METHODS: A total of 8 cases operated between September 2009 and 2016 at the Celal Bayar University, Faculty of Medicine were included in the study. Patients' clinicopathological features, type of surgery and follow up information were evaluated. Results: Six patients were male. The average age was 75.50. The lesions were located on the head and neck, and chest wall. Six patients had a history of the rapid growth of lesion. There was no metastasis at the time of diagnosis. None of the patients needed adjuvant therapy. Mean follow up time was 19.37 months. None of the patients developed recurrence or metastasis. Conclusion: This tumor resembles basal or squamous cell carcinoma. The histopathological evaluation may lead to misdiagnosis. Regional or distant metastasis is very rare. There is no consensus about adjuvant therapy. Screening for metastasis and close follow up are mandatory.

True retaining ligaments of face as surgical landmarks / Los verdaderos ligamentos de retención de la cara como marcadores quirúrgicos

The adherence of the overlying tissues to the underlying structures in the face is maintained by the retaining ligaments. True retaining ligaments named orbital, zygomatic and mandibular ligaments are a series of fibrous bands that run from periosteum to the dermis. The tethering effect of true retaining ligaments must be released for achieving a satisfactory movement of facial skin and Superficial Muscular Aponeurotic System (SMAS) during facial rejuvenation procedures. The aim of this study was to define the location of the true retaining ligaments of the face and to discuss their usability as surgical landmarks. The study was made on ten hemi-faces of formaline-fixed cadavers. Dissections resembling face-lift procedures were applied and ligaments were determined. The distances of the ligaments to lateral canthus, tragus and commissure and to the lines from tragus to lateral canthus and commissure were measured. Correlations were investigated statistically. The distances of the zygomatic and mandibular ligaments from the tragus were 66.50±10.78 mm and 114.80±9.76 mm respectively. The distances of the zygomatic ligament from the commissure and the commissure tragus line were 56.30±8.94 mm and 28.40±5.19 mm respectively. The distances of zygomatic and mandibular ligaments from the tragus were strongly correlated with a ratio of 3/5 and there was a strong correlation between the distances of the zygomatic ligament from the commissure and commissure- tragus line with a ratio of 2. The results of this study elucidated the possibility of the use of the true retaining ligaments as surgical landmarks for facial surgery.

La adherencia de los tejidos que recubren a las estructuras subyacentes en la cara se mantiene por los ligamentos de retención. Los ligamentos de retención verdaderos llamados ligamentos orbitales, cigomático y mandibular son una serie de bandas fibrosas que se extienden desde el periostio a la dermis. El efecto de la inmovilización de los verdaderos ligamentos de retención debe ser liberado para lograr un movimiento satisfactorio de la piel del rostro y del SMAS durante los procedimientos de estiramiento facial. El objetivo fue definir la ubicación de los verdaderos ligamentos de retención de la cara para discutir su utilidad como puntos de referencia quirúrgicos. El estudio se realizó sobre diez hemi-caras de cadáveres, fijadas con formalina. Las disecciones se asemejaron a los procedimientos de estiramiento facial, se aplicaron y determinaron los ligamentos. Se midieron las distancias de los ligamentos al canto lateral, trago, comisura y a las líneas de trago a canto lateral y comisura. Las correlaciones fueron analizadas estadísticamente. Las distancias de los ligamentos cigomático y mandibular desde el trago fueron 66,50±10,78 mm y 114,80±9,76 mm, respectivamente. Las distancias del ligamento cigomático a la comisura y la línea de comisura al trago fueron 56,30±8,94 mm y 28,40±5,19 mm, respectivamente. Las distancias de los ligamentos cigomático y mandibular desde el trago estaban correlacionadas de forma importante con una relación de 3/5 y había una fuerte correlación entre las distancias del ligamento cigomático desde la línea de comisura y el trago - con una relación de 2. Los resultados de este estudio han dilucidado la posibilidad de la utilización de los verdaderos ligamentos de retención como puntos de referencia quirúrgicos para la cirugía facial.

Lateral thoracic artery perforator-based flap: a new experimental model.

BACKGROUND: The aim of this study was to describe a new experimental perforator-based flap in rats, supplied by lateral thoracic artery perforator. METHODS: Through out the study, two control and two experimental groups were created consisting of six rats in each group. In the first control group (group 1), mid-axillary line and the fourth intercostal space intersection were used as the center of the flap. A 3 × 2 cm flap was designed and elevated above the cutaneous maximus muscle by transecting all connections with the muscle. In the second control group (group 2), the flap was extended caudally, and 3 × 6 cm flap was designed. Then, the flap was elevated in the same manner as it was described for group 1. In the first experimental group (group 3) 3 × 2 cm flap and in the second experimental group (group 4) 3 × 6 cm flap were designed like control groups. The flaps were islanded on a single musculocutan perforator arising from lateral thoracic artery. The surviving skin paddle areas were calculated on postoperative day 7. RESULTS: The flap viability was calculated 0% for control groups (groups 1 and 2), 100% for the first experimental group (group 3), between 33.3% and 37.7% for the second experimental group (group 4; mean ± standard deviation, 34.76% ± 1.92%). CONCLUSIONS: This new lateral thoracic artery perforator-based flap has a constant anatomy and reliable survival pattern. Also, easy harvesting and the possibility of designing two flaps per animal make this new flap an appealing model for pathophysiological or pharmacologic researches.

Asymmetry, handedness and auricle morphometry / Asimetría, lateralidad y morfometría de la oreja

The aims of this study were to determine various morphometric measurements of auricle, to investigate asymmetry and its relation with handedness in both sexes. Main morphometric measurements of both auricles and hand preferences were determined on 200 male and 200 female healthy university students. All measurements of the auricles were larger in males than the corresponding ones in females and all the differences except earlobe widths were statistically significant. All measurements of left and right auricles were statistically significantly different in both sexes except earlobe length in males, and distance from the highest point of the auricle to the bottom of the intertragic notch and earlobe length in females. Auricle length and distance from the highest point of the auricle to the bottom of the intertragic notch had higher values at the left side and all other measurements were larger at the right side. There was no significant difference between the measurements of the corresponding auricles of the righthanded and lefthanded subjects. All measurements were larger at the right side except auricle length and distance from the highest point of the auricle to the bottom of the intertragic notch in righthanded and lefthanded subjects and all differences except earlobe length were significantly different in righthanded subjects as in the total population but in lefthanded subjects the difference of the auricle width was not significant, either. There was an apparent asymmetry of right and left auricles of normal people in the current study which should be taken in to consideration in plastic surgeries of the external ear, designing the ear devices and forensic applications of earprints.

El objetivo de este estudio fue determinar diversas mediciones morfométricas de la oreja, para investigar la asimetría y su relación con el uso de las manos en ambos sexos. Se realizaron mediciones morfométricas de los pabellones auriculares y las manos de 400 estudiantes universitarios (200 hombres y 299 mujeres). Todas las medidas de las orejas fueron mayores en los hombres y todas las diferencias, excepto las correspondientes al ancho del lóbulo auricular, fueron estadísticamente significativas. Todas las mediciones de los pabellones auriculares izquierdos y derechos presentaron diferencias estadísticamente significativas en ambos sexos, excepto en el caso de la longitud del lóbulo auricular en los hombres, y la distancia desde el punto más alto de la oreja a la parte inferior de la incisura intertrágica en el lóbulo auricular de las mujeres. La longitud de la oreja y la distancia desde el punto más alto de la misma a la parte inferior de la escotadura intertrágica tenían valores más altos en el lado izquierdo y todas las demás mediciones fueron más elevadas en el lado derecho. No hubo diferencia significativa entre las mediciones de las orejas correspondientes a los sujetos diestros y zurdos. Todas las mediciones fueron superiores en el lado derecho, excepto la longitud del pabellón auricular y la distancia desde el punto más alto de la oreja a la parte inferior de la incisura intertrágica en sujetos diestros y sujetos zurdos, y todas las diferencias, excepto la longitud del lóbulo auricular, fueron significativamente diferentes en los sujetos diestros como en la población total, pero en sujetos zurdos la diferencia de la anchura de la oreja no fue significativa. Se encontró una aparente asimetría en las orejas derecha e izquierda de los sujetos del presente estudio que debe tenerse en consideración en las cirugías plásticas del oído externo, para el diseño de los dispositivos de audición y para su aplicación en estudios forenses de las huellas de la oreja.

The cranially based contralateral nasolabial flap for reconstruction of paranasal and periorbital surgical defects.

The importance of the paranasal and periorbital regions on the aesthetics of the face presents a variety of reconstructive challenges for surgical and traumatic defects of those regions. We used the cranially based nasolabial flap in patients with full-thickness soft-tissue defects of the paranasal and periorbital regions harvested from the contralateral side of the present defect. We present our experience in 25 patients of geriatric population (13 females and 12 males with a mean age of 76) with complex soft-tissue defects in the paranasal and periorbital regions whose defects were reconstructed with contralateral nasolabial skin flaps. Sizes of the defects changed between 2 × 3 cm and 6 × 7 cm. The flap sizes varied from a width of 2 to 5 cm (average 3 cm) and a length of 7 to 11 cm (average 8 cm). Primary closure of the donor sites of the flaps was possible in 24 of the patients in this series. Twenty-one flaps of this series (84%) healed without any necrosis and completely survived. The contralateral nasolabial flap is a very convenient, safe and reliable flap that can be used in medium to large paranasal and periorbital defects. Optimal aesthetic results for a variety of central facial defects could be obtained with this flap, especially when the ipsilateral nasolabial flap cannot be used due to various reasons.

Tension adjusted multivectorial static suspension with plantaris tendon in facial paralysis.

Facial paralysis in the midface causes loss of cheek tonus, asymmetry at rest, and inability to smile. Static suspension is generally performed in patients who cannot tolerate time-consuming dynamic reanimation. Current methods for static slings are overly simplistic. A sling, which is generally fascia lata or palmaris tendon, is placed between the modiolus and the zygomatic arch or the temporalis fascia, with further extension to the midline of the upper end lower lips in 1 vector. Recently, sutures are placed in a multivectorial approach, but suture failure via breakage is the main problem. In this study, the long, thin, and powerful plantaris tendon was used and divided into 3 slips. Placement of these slips and their tension adjustment were revised to provide strong and long-lasting upper lip and the modiolus pull, along with creation of a well-defined nasolabial fold, and to create sufficient cheek tonus. The first slip was positioned at 35 to 45 degrees to the horizontal plane between the modiolus and the upper preauricular area, second slip at 55 to 60 degrees between the upper lip and the deep temporal fascia, and the third slip at 0 to 10 degrees between the lower lip and lower preauricular area with gradually decreasing tension from above to below in 9 patients. Upper 2 slings were also sutured to the dermis of the nasolabial fold to define it optimally. Results were assessed both objectively and subjectively. Symmetry at rest, sufficient cheek tightness to prevent drooling, and a well-defined fold were obtained.

Nonsyndromic giant basal cell carcinoma with follicular differentiation and multifocal localized basal cell carcinoma.

Basal cell carcinoma is the most common malignant tumor of the skin. The most important feature is its very slow growth rate. It takes many years to reach gigantic dimensions. Various syndromes have been defined in which basal cell carcinoma exists in multiple localizations in a single patient. A case of basal cell carcinoma with multiple localizations and gigantic dimensions which is not classified as a syndrome is described in this case report.