Ruptured pseudoaneurysm of the internal maxillary artery in zygomaticomaxillary fracture: a case report.

Post-traumatic pseudoaneurysms of internal maxillary artery are rare, but may be life-threatening. When arterial damage leads to pseudoaneurysm formation, delayed intractable epistaxis can occur. We report our experience with the diagnosis and management of a ruptured internal maxillary arterial pseudoaneurysm that was discovered preoperatively in a patient with a zygomaticomaxillary complex (ZMC) fracture. He presented to the emergency room with epistaxis, which ceased shortly, and sinus hemorrhage was observed with a fracture of the posterior maxillary wall. The patient was scheduled for open reduction and internal fixation (ORIF) of the ZMC fracture. However, immediately before surgery, uncontrolled epistaxis of unknown origin was observed. Angiography indicated a pseudoaneurysm of the posterior superior alveolar artery. Selective endovascular embolization was performed, and hemostasis was achieved. After radiologic intervention, ORIF was successfully implemented without complications. Our case shows that in patients with a posterior maxillary wall fracture, there is a risk of uncontrolled bleeding in the perioperative period that could be caused by pseudoaneurysms, which should be considered even in the absence of typical symptoms.

Use of Keystone Flaps in Consideration of the Facial Aesthetic Subunit Concept as an Alternative Reconstructive Option for Nasal Defect Coverage.

ABSTRACT: Nasal defect coverage has some challenging aspects for plastic surgeons because of the midfacial location of the nose and the relationship between convexities and concavities of nasal subunits. The authors described our experience with performing keystone flap (KF) nasal reconstruction in accordance with the facial aesthetic subunit concept and demonstrated the expanding versatility of KFs in nasal reconstruction. Between January 2017 and February 2020, 15 patients (average age, 72.07 ±â€Š13.00 years, range: 38-88 years) underwent KF reconstruction for nasal defects. We performed KF reconstruction in accordance with the facial aesthetic subunit concept. Data, including the defect causes and locations, defect sizes, flap sites and sizes, types of KFs, flap survival, complications, and follow-up period for each patient were reviewed retrospectively. Cosmetic outcomes were evaluated by independent plastic surgeons and patients through satisfactory postoperative surveys. Sixteen defects occurred in 15 patients. The defect sizes ranged from 0.8 × 1 cm to 2.5 × 3 cm. The flap sizes ranged from 1.5 × 3.5 cm to 4 × 6 cm. All defects were successfully covered with KFs from adjacent subunits. All flaps survived without any postoperative complications. At the mean follow-up period of 8.33 ±â€Š2.92 months, the objective cosmetic outcomes were rated favorably, and the average subjective patient satisfaction score was 7.93 ±â€Š1.28 on a scale of 1 to 10. We suggest that using KF reconstruction in consideration of the facial aesthetic subunit concept can be a promising alternative modality for covering nasal defects with outstanding aesthetic outcomes.

Keystone design perforator island flap in facial defect reconstruction.

Facial defect coverage is a common subject in the field of reconstructive surgery. There are many methods for facial defect reconstruction, and reconstructive surgeons should choose the most appropriate method on a case-by-case basis to achieve both functional and aesthetic improvement. Among various options for facial reconstruction, the local flap technique is considered the best reconstructive modality to provide good tissue matches of color and texture, which is consistent with the ideal goal of reconstruction (replacement of like-with-like). Keystone design perforator island flap (KDPIF), devised by Behan in 2003, has been applied to various fields of reconstructive surgery in the past decade due to its design simplicity, robust vascular supply, and reproducibility. Several studies have reported KDPIF reconstruction of facial defects, such as large parotid defects, small-to-moderate nasal defects, and eyelid defects. However, KDPIF has been used relatively less in facial defects than in other body regions, such as the trunk and extremities. The purpose of this review is to provide an organized overview of facial KDPIF reconstruction including the classification of KDPIF, modifications, physiology, mechanism of flap movement, consideration of facial relaxed skin tension lines and aesthetics, surgical techniques, clinical applications, and precautions for successful execution of KDPIF reconstruction.

Circumferential penile defect reconstruction with pull-up double-opposing keystone-designed perforator island flaps: A case report.

RATIONALE: The challenges with reconstruction of penile defects are plenty. In addition, no single and universally accepted reconstructive method exists for penile defect repair. Herein, we present the application of a circumferential penile shaft defect reconstruction using pull-up double-opposing keystone-designed perforator island flaps (KDPIFs) in one patient. This is the first case report of a circumferential penile shaft defect reconstruction using KDPIFs. PATIENT CONCERNS: A 43-year-old man who injected petroleum jelly into his penis 10 years ago presented with multiple firm nodular mass-like lesions adherent to the overlying skin along the penile shaft. Our urologic surgeon removed the foreign bodies and performed a primary closure with undermining. However, wound dehiscence developed, and skin necrosis was exacerbated 5 days postoperatively. DIAGNOSES: We performed debridement, and the final post-debridement defect was circumferential (5.5 × 12 cm) from the base of the glans to the midpoint of the penile shaft. INTERVENTIONS: We covered the defect using pull-up double-opposing KDPIFs (10 × 13 cm each) based on the hot spots of the superficial external pudendal artery perforators on each side from the suprapubic area to the scrotum. OUTCOMES: The flaps survived perfectly, with no postoperative complications. The patient was satisfied with the final outcome and had no erectile dysfunction or shortening of penile length after a 6-month follow-up. LESSONS: We successfully reconstructed a circumferential penile defect with pull-up double-opposing KDPIFs both esthetically and functionally. Our technique can be a good alternative modality for extensive penile defect reconstruction.