Orbital wall restoration with primary bone fragments in complex orbital fractures.

BACKGROUND: Complex orbital fractures are impure orbital fractures because they involve the orbital walls and mid-facial bones. The author reported an orbital wall restoration technique in which the primary orbital wall fragments were restored to their prior position in complex orbital fractures in 2020. As a follow-up to a previous preliminary study, this study retrospectively reviewed the surgical results of complex orbital wall fractures over a 4-year period and compared the surgical outcomes by dividing them into groups with and without balloon restoration. METHODS: Data of 939 patients with facial bone fractures between August 2018 and August 2022 were reviewed. Of these, 154 had complex orbital fractures. Among them, 44 and 110 underwent reduction with and without the balloon technique respectively. Pre- and postoperative Naugle exophthalmometer (Good-Lite Co.) scales were evaluated. The orbital volume and orbital volume ratio were calculated from preoperative and 6 months postoperative computed tomography images. RESULTS: Among 154 patients with complex orbital fractures, 44 patients underwent restoration with the balloon technique, and 110 patients underwent restoration without it. The Naugle scale did not differ significantly between the two groups, but the orbital volume ratio significantly decreased by 3.32% and 2.39% in groups with and without the balloon technique and the difference in OVR was significantly greater in patients in the balloon restoration group compared with the control group. Postoperative balloon rupture occurred in six out of 44 cases (13.64%). None of the six patients with balloon rupture showed significant enophthalmos at 6 months of follow-up. CONCLUSION: The balloon rupture rate was 13.64% (6/44 cases) with marginal screw fixation, blunt screws, and extra protection with a resorbable foam dressing. Furthermore, we restored the orbital wall with primary orbital fragments using balloon support in complex orbital wall fractures.

Facial injury burden of personal mobility devices: a single-center retrospective analysis.

BACKGROUND: Personal mobility devices (PMDs) have become an increasingly popular transport modality globally. With increasing social interest in and demand for PMDs, the number of individuals visiting emergency departments with PMD-related injuries has also increased annually. This study aimed to evaluate injury patterns and treatment costs for patients treated in the department of plastic surgery in a trauma center. METHODS: In this retrospective study, data concerning patients with PMD-related injuries from January 2017 to December 2021 were reviewed. The data retrieved included age, sex, alcohol consumption, helmet use, the type of impact, onset of injury, place of first visit, type of injury, admission status, operation status, and treatment cost. Multiple linear regression analysis was performed to determine the effects of various factors on cost. RESULTS: Data were collected from 93 patients. Until 2019, the annual number of PMD-related accidents was less than 10; however, this number increased sharply in 2020. The average cost of hospitalization was USD 7,698 whereas the average cost of non-hospitalization was USD 631. Only fractures had a significant association with total cost in linear regression analysis (p < 0.001). CONCLUSION: The prevalence of PMD use and related injuries requiring plastic surgery during the study period showed significant health and financial costs both to the patients involved and to society. This cost could be reduced through stricter regulations concerning PMD use, advocating the use of protective gear, and promoting greater awareness of safety measures and of the consequences of PMD-related accidents.

Sequencing of panfacial fracture surgery: a literature review and personal preference.

BACKGROUND: Treating panfacial fractures (PFFs) can be extremely difficult even for experienced surgeons. Although several authors have attempted to systemize the surgical approach, performing surgery by applying a unidirectional sequence is much more difficult in practice. The purpose of this study was to review the literature on PFF surgery sequence and to understand how different surgical specialists-plastic reconstructive surgery (PRS) and oral maxillofacial surgery (OMS)-chose sequence and review PFFs fixation sequence in clinical cases. METHODS: The PubMed and Google Scholar databases were scoured for publications published up until May 2020. Data extracted from the studies using standard templates included fracture part, fixation sequence, originating specialist, and the countries. Bibliographic details like author and year of publication were also extracted. Also, we reviewed the data for PFFs patients in the Trauma Registry System of Dankook University Hospital from 2011 to 2021. RESULTS: In total, 240 articles were identified. This study comprised 22 studies after screening and full-text analysis. Sixteen studies (12 OMS specialists and 4 PRS specialists) used a "bottom-top" approach, whereas three studies (1 OMS specialist and 2 PRS specialists) used a "top-bottom" method. However, three studies (only OMS specialists) reported on both sequences. In our hospital, there were a total of 124 patients with PFF who were treated during 2011 to 2021; 64 (51.6%) were in upper-middle parts, 52 (41.9%) were in mid-lower parts, and eight (6.5%) were in three parts. CONCLUSION: Bottom-top sequencing was mainly used in OMS specialists, and top-bottom sequencing was used at a similar rate by two specialists in literature review. In our experience, however, it was hard to consistently implement unidirectional sequence suggested by a literature review. We realigned the reliable and stable buttresses first with tailoring individually for each patient, rather than proceeding in the unidirectional sequence like bottom-top or top-bottom.

Orbital wall restoration with primary bone fragments in complex orbital fractures: A preliminary study.

BACKGROUND: We have reported orbital wall restoration surgery with primary orbital wall fragment in pure blowout fractures using a combination of transorbital and transnasal approach in pure blow out fractures. However, this method was thought to be difficult to use for complex orbital wall fractures, since the sharp screw tip that fixate the maxillary wall increases the risk of balloon ruptures. In this study, we reviewed 23 cases of complex orbital fractures that underwent orbital wall restoration surgery with primary orbital wall fragment and evaluated the result. METHODS: A retrospective review was conducted of 23 patients with complex orbital fracture who underwent orbital restoration surgery with primary orbital wall fragments between 2012 and 2019. The patients underwent orbital wall restoration surgery with primary orbital wall fragment with temporary balloon support. The surgical results were evaluated by the Naugle scale and a comparison of preoperative and postoperative orbital volume ratio. Complex fracture type, type of screw used for fixation and complications such as balloon rupture were also investigated. RESULTS: There were 23 patients with complex orbital fracture that used transnasal balloon technique for restoration. 17 cases had a successful outcome with no complications, three patients had postoperative balloon rupture, two patients had soft-tissue infection, and one patient had balloon malposition. CONCLUSION: The orbital wall restoration technique with temporary balloon support can produce favorable results when done correctly even in complex orbital wall fracture. Seventeen cases had favorable results, six cases had postoperative complications thus additional procedure seems necessary to complement this method.

The Influence of Dissection Range of the Facial Nerve on Transient Postoperative Facial Palsy in Mandibular Condyle Fractures.

PURPOSE: This study examined the relation between dissection range of facial nerve branches and transient postoperative facial palsy caused by nerve traction for open treatment of mandibular condyle fractures using a preauricular approach. MATERIALS AND METHODS: This retrospective study included 58 patients who underwent rigid fixation of condylar head and upper neck fractures. Patients were divided into 3 groups based on dissection range of the frontal and zygomatic branches. For group 1 (n = 22), the dissection range was extended anteriorly and posteriorly from the condylar borders through the retroparotid approach. The transparotid approach was used in groups 2 (n = 19) and 3 (n = 17) in which nerve dissection was limited to the condylar borders and was extended only anteriorly, respectively. Using multivariate correlation and multiple regression analyses, differences in duration of nerve traction and angle difference by traction from the natural course of the nerve were analyzed according to dissection range, and the recovery period for facial palsy was evaluated. RESULTS: The duration of nerve traction for group 2 was 77.53 minutes, which was longer than that for groups 1 (66.00 minutes) and 3 (65.41 minutes). The angle differences by traction were 62.42° and 58.00° for the frontal and zygomatic branches in group 2, respectively, which were considerably greater than those in groups 1 (23.32° and 20.14°) and 3 (37.24° and 28.88°). In consequence, group 2 showed the longest recovery, requiring 64.47 days for the frontal branch and 51.63 days for the zygomatic branch. The angle difference by traction had a greater influence on the recovery period than duration of nerve traction. CONCLUSIONS: Duration of nerve traction and angle difference by traction were quantitatively dependent on the dissection range of facial nerve branches and were related to the recovery period for transient facial palsy.

"Radiological morphometric analysis of the zygomatic arch: Application of osteosynthesis on the upper arch border for rigid fixation".

BACKGROUND: This study was designed to introduce a novel method of applying osteosynthetic materials to the upper zygomatic arch border for fracture fixation through a temporal incision, and analyze the radiologic morphometric dimensions of the arch to verify its validity. METHODS: Radiological morphometry was analyzed in 51 adult patients with unilateral isolated zygomatic arch fractures. Frequent fracture sites, sites of minimal thickness and height, and their correlation were evaluated, as were the locations and dimensions of fixation vantage points. The novel surgical method based on the results was implemented in 17 clinical cases. RESULTS: Frequent fracture sites, occurring 4.40, 16.47 and 30.48 mm posterior to the arch origin, did not correlate to sites of minimal height and thickness. Arch minimal thickness and height locations were 12.23 and 27.09 mm behind its origin, respectively. Fixation vantage point dimensions varied from point to point, with upper thickness ranging from 1.67 to 4.86 mm and mid-portion thickness ranging from 2.06 to 7.36 mm, and height ranging from 8.99 to 22.53 mm. Arch vertical axis inclination ranged from 6.51° to 16.47°, which increased as the arch stretches posteriorly. These results suggested the use of 1.5 mm-wide plates and 1 mm-diameter screws with 6-8 mm length. Patients received surgery based on these morphometry results for satisfactory stabilization. CONCLUSIONS: This study introduces a new method for open reduction and internal fixation of arch fractures, with morphometric analysis of the arch verifying the validity of tangential plate application to the upper border.

Unrecognized intraorbital wooden foreign body.

Intraorbital wooden foreign bodies may present difficulties in diagnosis due to their radiolucent nature. Delayed recognition and management can cause significant complications. We present a case report that demonstrates these problems and the sequela that can follow. A 56-year-old man presented with a 3-cm laceration in the right upper eyelid, sustained by a slipping accident. After computed tomography (CT) scanning and ophthalmology consultation, which revealed no fractures and suggested only pneumophthalmos, the wound was repaired by a plastic surgery resident. Ten days later, the patient's eyelid displayed signs of infection including pus discharge. Antibiotics and revisional repair failed to solve the infection. Nearly 2 months after the initial repair, a CT scan revealed a large wooden fragment in the superomedial orbit. Surgical exploration successfully removed the foreign body and inflamed pocket, and the patient healed uneventfully. However, the prolonged intraorbital infection had caused irreversible damage to the superior rectus muscle, with upgaze diplopia persisting 1 year after surgery and only minimal muscle function remaining. We report this case to warn clinicians of the difficulties in early diagnosis of intraorbital wooden foreign bodies and the grave prognosis of delayed management.

Cranial Defect Overlying a Ventriculoperitoneal Shunt: Pressure Gradient Leading to Free Flap Deterioration?

We report a case of free flap deterioration which may have been induced by pressure gradient resulting from cranial defect overlying a ventriculoperitoneal shunt (VP shunt). The patient, male and aged 78, had a VP shunt operation for progressive hydrocephalus. Afterwards, the scalp skin flap surrounding the VP shunt collapsed and showed signs of necrosis, exposing part of the shunt catheter. After covering the defect with a radial forearm free flap, the free flap site showed signs of gradual sinking while the vascularity of the flap remained unimpaired. An agreement was reached to remove the shunt device and observe the patient for any neurological symptoms, and after the shunt was removed and the previous cranial opening filled with fibrin glue by Neurosurgery, we debrided the deteriorated flap and provided coverage with 2 large opposing rotational flaps. During 2 months' outpatient follow-up no neurological symptoms appeared, and the new scalp flap displayed slight depression but remained intact. The patient has declined from any further follow-up since.

Nipple-Areola Complex Necrosis after Nipple-Sparing Mastectomy with Immediate Autologous Breast Reconstruction.

BACKGROUND: Autologous or implant-based breast reconstruction after nipple-sparing mastectomy is increasingly preferred worldwide as a breast cancer treatment option. However, postoperative nipple-areola complex (NAC) necrosis is the most significant complication of nipple-sparing mastectomy. The purpose of our study was to identify the risk factors for NAC necrosis, and to describe the use of our skin-banking technique as a solution. METHODS: We reviewed cases of immediate autologous breast reconstruction after nipple-sparing mastectomy at our institution between June 2005 and January 2014. The patients' data were reviewed and the risk of NAC necrosis was analyzed based on correlations between patient variables and NAC necrosis. Moreover, data pertaining to five high-risk patients who underwent the donor skin-banking procedure were included in the analysis. RESULTS: Eighty-five patients underwent immediate autologous breast reconstruction after nipple-sparing mastectomy during the study period. Partial or total NAC necrosis occurred in 36 patients (43.4%). Univariate analysis and binary regression modeling found that body mass index, smoking history, radiation therapy, and mastectomy volume were significantly associated with NAC necrosis. Of the 36 cases of NAC necrosis, 31 were resolved with dressing changes, debridement, or skin grafting. The other five high-risk patients underwent our prophylactic skin-banking technique during breast reconstruction surgery. CONCLUSIONS: NAC necrosis is common in patients with multiple risk factors. The use of the skin-banking technique in immediate autologous breast reconstruction is an attractive option for high-risk patients. Banked skin can be used in such cases without requiring additional donor tissue, with good results in terms of aesthetic and reconstructive outcomes.

A novel technique for robot assisted latissimus dorsi flap harvest.

BACKGROUND: A robotic surgery technique of harvesting the latissimus dorsi muscle flap has technical advantages over endoscopic harvest and cosmetic advantages over the open technique. The authors introduce a new transaxillary gasless technique using an articulated long retractor for robot assisted latissimus dorsi flap harvest. METHODS: Twelve robot assisted latissimus dorsi muscle flaps were harvested: 3 cases of delayed reconstruction following tissue expander insertion or breast conserving surgery; 4 cases of immediate reconstruction following nipple-sparing mastectomy; and 5 cases of chest wall deformity correction in patients with Poland syndrome. A specially designed articulated long retractor was used to maintain adequate working space and enable latissimus dorsi muscle dissection without gas insufflation. RESULTS: Twelve muscle flaps were successfully harvested in 12 patients without converting to an open technique. The mean docking time was 54.6 min, and the mean operative time and robotic time were 400.4 min and 85.8 min, respectively. There were no donor site complications or flap problems. Average follow-up was 15.7 months. All patients were satisfied with their esthetic results, especially the absence of visible scars. CONCLUSION: The novel robot assisted latissimus dorsi harvest technique is a safe alternative to the conventional method.

Medial Wall Orbital Reconstruction using Unsintered Hydroxyapatite Particles/Poly L-Lactide Composite Implants.

BACKGROUND: Poly-L-lactide materials combined with hydroxyapatite (u-HA /PLLA) have been developed to overcome the drawbacks of absorbable materials, such as radiolucency and comparably less implant strength. This study was designed to evaluate the usefulness of u-HA/PLLA material in the repair of orbital medial wall defects. METHODS: This study included 10 patients with pure medial wall blow-out fractures. The plain radiographs were taken preoperatively, immediately after, and 2 months after surgery. The computed tomography scans were performed preoperatively and 2 months after surgery. Patients were evaluated for ease of manipulation, implant immobility, rigidity and complications with radiologic studies. RESULTS: None of the patients had postoperative complications, such as infection or enophthalmos. The u-HA/PLLA implants had adequate rigidity, durability, and stable position on follow-up radiographic studies. On average, implants were thawed 3.4 times and required 14 minutes of handling time. CONCLUSION: The u-HA/PLLA implants are safe and reliable for reconstruction of orbital medial wall in terms of rigidity, immobility, radiopacity, and cost-effectiveness. These thin yet rigid implants can be useful where wide periosteal dissection is difficult due to defect location or size. Since the u-HA/PLLA material is difficult to manipulate, these implants are not suitable for use in complex 3-dimensional defects.

Vascularized Partial Free Toe Tissue Transfer Under Local Anesthesia.

BACKGROUND: This study was designed to introduce free toe soft tissue transfer using local infiltration anesthesia in patients not suitable for general anesthesia and local tissue coverage. METHODS: From January 2006 to August 2012, a total of 11 traumatic fingertip defects were reconstructed by toe soft tissue transfer. All procedures except 1 were done as primary reconstructions, with either the lateral side of the great toe (5 cases) or the medial side of the second toe (6 cases) used as a donor. Postoperative follow-up periods were between 8 months to 2 years and 6 months. RESULTS: Flap sizes varied from 1.0 × 2.0 to 2.0 × 3.5 cm. The mean operative times were 4 hours 29 minutes for cases done by a single team and 3 hours 21 minutes for cases done by a 2-team approach. Approximately 5.8 mL of local anesthetic agent was used in each finger and 5.9 mL was used in the toes for a total of 11.7 mL. All flaps survived and were fully taken without complications, except 1 case that presented partial necrosis. CONCLUSIONS: Fingertip soft tissue reconstruction by free toe tissue transfer under local anesthesia uses a more limited operative field, with a shorter operative time, enabling reconstruction in patients not suitable for general anesthesia. This is even more so with a microsurgical 2-team approach, which reduces the volume of anesthetic agent needed, making this method a sufficiently realistic option for fingertip soft tissue reconstruction.

Comparison of the complications in vertical rectus abdominis musculocutaneous flap with non-reconstructed cases after pelvic exenteration.

BACKGROUND: Perineal reconstruction following pelvic exenteration is a challenging area in plastic surgery. Its advantages include preventing complications by obliterating the pelvic dead space and minimizing the scar by using the previous abdominal incision and a vertical rectus abdominis musculocutaneous (VRAM) flap. However, only a few studies have compared the complications and the outcomes following pelvic exenteration between cases with and without a VRAM flap. In this study, we aimed to compare the complications and the outcomes following pelvic exenteration with or without VRAM flap coverage. METHODS: We retrospectively reviewed the cases of nine patients for whom transpelvic VRAM flaps were created following pelvic exenteration due to pelvic malignancy. The complications and outcomes in these patients were compared with those of another nine patients who did not undergo such reconstruction. RESULTS: Flap reconstruction was successful in eight cases, with minor complications such as wound infection and dehiscence. In all cases in the reconstructed group (n=9), structural integrity was maintained and major complications including bowel obstruction and infection were prevented by obliterating the pelvic dead space. In contrast, in the control group (n=9), peritonitis and bowel obstruction occurred in 1 case (11%). CONCLUSIONS: Despite the possibility of flap failure and minor complications, a VRAM flap can result in adequate perineal reconstruction to prevent major complications of pelvic exenteration.

Can macrocirculation changes predict nonhealing diabetic foot ulcers?

PURPOSE: Transcutaneous partial oxygen tension (TcpO2) is considered the gold standard for assessment of tissue oxygenation, which is an essential factor for wound healing. The purpose of this study was to evaluate the association between macrocirculation and TcpO2 in persons with diabetes mellitus. SUBJECTS AND SETTING: Ninety-eight patients with diabetic foot ulcers participated in the study (61 men and 37 women). The subjects had a mean age of 66.6 years (range, 30-83 years) and were treated at the Diabetic Wound Center of Korea University Guro Hospital, Seoul, Republic of Korea. METHODS: Macrocirculation was evaluated using 2 techniques: computed tomographic angiography and Doppler ultrasound. Macrocirculation scores were based on the patency of the two tibial arteries in 98 patients. Computed tomographic angiography and Doppler ultrasound scores (0-4 points) were given according to intraluminal filling defects and arterial pulse waveform of each vessel, respectively. Tissue oxygenation was measured by TcpO2. Macrocirculation scores were statistically analyzed as a function of the TcpO2. RESULTS: Statistical analysis revealed no significant linear trend between the macrocirculation status and TcpO2. Biavariate analysis using the Fisher exact test, Mantel-Haenszel tests, and McNemar-Bowker tests also found no significant relationship between macrocirculation and TcpO2. CONCLUSIONS: Computed tomographic angiography and Doppler ultrasound are not sufficiently reliable substitutes for TcpO2 measurements in regard to determining the optimal treatment for diabetic patients.

Comparison of Mechanical Stability between Fibular Free Flap Reconstruction versus Locking Mandibular Reconstruction Plate Fixation.

BACKGROUND: The fibular free flap has been used as the standard methods of segmental mandibular reconstruction. The objective of mandibular reconstruction not only includes restored continuity of the mandible but also the recovery of optimal function. This paper emphasizes the advantage of the fibular free flap reconstruction over that of locking mandibular reconstruction plate fixation. METHODS: The hospital charts of all patients (n=20) who had a mandibular reconstruction between 1994 and 2013 were retrospectively reviewed. Eight patients had plate-only fixation of the mandible, and the remaining 12 had vascularized fibular free flap reconstruction. Complications and outcomes were reviewed and compared between the 2 groups via statistical analysis. RESULTS: Overall complication rates were significantly lower in the fibular flap group (8.3%) than in the plate fixation group (87.5%; p =0.001). Most (7/8) patients in the plate fixation group had experienced plate-related late complications, including plate fracture or exposure. In the fibular flap group, no complications were observed, except for a single case of donor-site wound dehiscence (1/12). CONCLUSION: The fibular free flap provides a more stable support and additional soft tissue support for the plate, thereby minimizing the risk of plate-related complications. Fibular free flap is the most reliable option for mandibular reconstruction, and we believe that the flap should be performed primarily whenever possible.

Efficacy and safety of fresh fibroblast allografts in the treatment of diabetic foot ulcers.

BACKGROUND AND OBJECTIVE: Various types of allogenic skin substitutes composed of cryopreserved keratinocytes, fibroblasts, or both have been used for treatments of diabetic foot ulcers, but the effects have generally not been dramatic because cryopreservation impairs cell activities. The purpose of the study was to evaluate the use of non-cryopreserved fresh human fibroblast allografts in treating diabetic foot ulcers. MATERIALS AND METHODS: Human dermal fibroblasts from healthy teenagers were cultured and applied over the foot ulcers of 37 patients with diabetes. Control treatment was performed in 18 patients. Eight weeks after treatment, the percentages of complete healing, mean healing times, and patient satisfaction were compared, with follow-up ranging from 6 to 40 months. RESULTS: Our study showed that 83.8% of the treated group and 50.0% of the control group experienced complete healing. The times required for complete healing were 30.9+/-10.1 and 47.2+/-7.8 days in the treated and control groups, respectively. Patient satisfaction with fresh fibroblast treatment was also superior to satisfaction with the conventional method (mean scores: 8.0+/-1.0 and 4.9+/-1.4, respectively). No adverse events related to the study treatment occurred. CONCLUSION: The use of fresh human fibroblast allografts was found to be a safe and effective treatment for diabetic foot ulcers. The authors have indicated no significant interest with commercial supporters.