Versatile use of the posterior interosseous flap in the reconstruction of complex upper limb defects.

BACKGROUND: Reconstruction of the complex upper extremity defects is a challenging procedure for reconstructive surgeons because of the complex anatomical and functional structure of this region. In reconstruction, local and regional flap options involving the composite tissues are restricted. The posterior interosseous flap (PIO) has been presented 'in a single study' with a wide variety of uses, and in this study, the versatility of PIO has been tried to be emphasized by its multitude uses as well as its chance at adaptability to each case. Hence, due to this, the objective to highlight the versatile utility of the PIO flap in clinical practice and to present a good option for the reconstruction of complex upper limb defects for various cases have been targeted. METHODS: We used 26 PIO flaps in 25 patients (18 male and seven female patients) with upper limb defects. The main etiological causes were burn contracture, traffic accident, firearm and acute burn injury. Twenty-two flaps were harvested as fasciocutaneous and four flaps as osteo-fasciocutaneous manner, which were applied to the metacarpal defects. In this study, 25 flaps were transferred as pedicled flaps, of which 23 and 2 flaps had reverse and antegrade blood flows, respectively, whereas one flap was used as a free flap. RESULTS: The mean follow-up period was 14 months. All flaps except one, which had partial necrosis and secondary healed, survived completely. All patients were able to gain basic functions for daily routine activities in the late postoperative period. Patients and/or their parents were satisfied with the postoperative functional and aesthetic improvements. CONCLUSION: Many advantages of the PIO flap make it useful for the reconstruction of upper limb complex defects. It can be versatilely used based on changing its flow direction and enrichment of contents.

Novel Surgical Technique for Repair of Zygomatic Fractures: Lever Technique.

BACKGROUND: Zygoma is a very crucial component for the anteroposterior positioning of the midface and for the maintenance of facial contours. Zygomatic fractures are considered as the second most common type of facial fractures following nasal fractures. We have developed a new reduction technique called "lever," which is based on the application of lifting force as an alternative to the methods in which the pulling force is applied. PATIENTS: Over a 12-year period, 90 patients were treated with minimal access approach and 130 patients were treated with open reduction internal fixation (ORIF), using the lever technique. RESULTS: In the follow-up period, no complications occurred in any of the patients who underwent minimal access approach. Miniplate removal operation was performed in 3 of the patients. Enophthalmos developed in one patient. Since 4 of the 7 suboptimal reduction patients did not experience any functional or cosmetic problems, no treatment was necessary and the remaining 3 patients underwent fat graft due to the presence of malar depression. CONCLUSION: This minimally invasive surgical procedure we have developed can be successfully used both in the minimal access approach and in ORIF, especially in delayed cases. We recommend this method due to the reasons that it is safe to conduct, easy to learn, fast to apply, simple to perform, and also economical to deploy.

HISTORIQUE: L'os zygomatique est décisif pour le positionnement antéropostérieur de la partie médiane du visage et la préservation des contours du visage. Les fractures zygomatiques sont considérées comme la deuxième cause de fractures du visage en importance, après les fractures du nez. Les auteurs ont créé une nouvelle technique de réduction, la « technique de levier ¼, qui repose sur l'application d'une force de soulèvement plutôt que sur les méthodes reliées à une force de tension. PATIENTS: Sur une période de 12 ans, 90 patients ont subi un abord d'accès minime et 130, une fixation interne par réduction chirurgicale (FIRC) à l'aide de la technique de levier. RÉSULTATS: Pendant la période de suivi, aucun patient ayant subi l'abord d'accès minime n'a souffert de complications. Trois ont dû faire extraire des mini-plaques. Un patient a souffert d'énophtalmie. Puisque quatre des sept patients ayant subi une réduction sous-optimale ne présentaient aucun problème fonctionnel ou esthétique, ils n'ont pas eu besoin de traitement supplémentaire, et les trois autres ont reçu une greffe de tissus adipeux en raison d'un enfoncement malaire. CONCLUSION: Cette intervention peu effractive mise au point par les auteurs peut être utilisée avec succès pour l'abord d'accès minime et la FIRC, surtout dans les cas différés. Ils recommandent cette méthode parce qu'elle est sécuritaire, facile à apprendre, facile à appliquer et à exécuter et peu coûteuse.

Experiences with a modified preauricular mini incision with subdermally dissection in condylar and subcondylar fractures of the mandible.

OBJECTIVE: Condylar and subcondylar fractures (CSFs) are among the most common mandible fractures. If reduction of these fractures is not carried out correctly, serious complications can result, including infection, damage to temporomandibular joint (TMJ) function, malocclusion, nonunion, malunion, and ankylosis of the TMJ. METHODS: We used a preauricular, mini-incision, open technique (PMIOT) for CSF of the mandible. 66 patients (48 males, 18 females), with a total of 72 CSFs of the mandible, were repaired with PMIOT between 2011 and 2016. Average age was 37.8 years (range: 8-78). CSFs were located on the right side, left side, and bilaterally in 21, 27 and six patients, respectively. We used only one mini incision of length 2 cm for non-displaced subcondylar fractures. However, we had to perform a second mini incision for condylar fractures displaced by more than 45°, where subcondylar fractures overlapped, or where there was deep surgical exposure and difficulty with reduction. RESULTS: No early complications, such as bleeding, hematoma, seroma, infection, or parotid fistula, were seen in any patients. Temporary facial nerve paresis was reported in three patients, but these recovered spontaneously with conservative treatment within 15 days. Permanent facial nerve paralysis occurred in none of the patients. CONCLUSION: We believe that PMIOT is an effective, reliable, and feasible method for repair of CSF. It does not need any expensive and sophisticated tools, and has low complication rates. The mini incision used in our technique results in both a hidden scar and protection of essential structures in the region.

Total Lower Lip Reconstruction With Functional Gracilis Free Muscle Flap.

Free flaps based on static slings principles cannot provide esthetic and functional outcomes at a desired level in total or close to total lip loss. Therefore, dynamic methods have become a current issue in recent years and especially the idea of functional gracilis free muscle flap has been suggested. In this study, we present a case of a successful total lower lip repair with this flap.In a 78-year-old female patient who was diagnosed with squamous cell carcinoma involving the entire lower lip, bilateral modified radical neck dissection and full-thickness total resection with 1 cm surgical margin so as to include both commissures of the tumor were performed and then a free gracilis muscle flap was transferred from the same side. After microvascular anastomoses, the motor nerve of the flap was coapted to the marginal mandibular branch of the fascial nerve. The entire intra- and extraoral surfaces of the flap were covered with a partial-thickness skin graft which was taken from the right thigh. There was no any intra- or early postoperative complication. The skin graft and flap survived without any problem.In the controls of the patient who was followed-up for 8 postoperative months, it was observed that the gracilis muscle flap was well-adapted to its place, gained a very good tonus, its volume reduced over time and reached to ideal dimensions, and the overlying skin graft provided a good color and texture match with the surrounding tissues. The motor activity of the muscle was monitored with the Tinel's test. The speech and facial expressions of the patient were very clear. Despite the patient has an edentulous mandible and was not using prosthesis, her feeding with fluid and solid foods was free of problems, oral competence was highly sufficient, and there was no any drooling. Esthetic appearance was very good and intraoral vestibular depth was sufficient. The mouth opening was 3 cm. When comparing with upper orbicularis oculi muscle on the electroneuromyography (ENMG) ordered at the 8th month, a similar nerve conduction time (3.3 versus 3.8 ms) and contraction amplitude (0.5 versus 0.4 mV) values were obtained from the gracilis muscle. Follow-up of the patient is still continued with no tumor recurrence observed during this period.Being the real dynamic flap and its tonus of the functional gracillis free muscle flap in opposite to the static methods provides a significant superiority over the other options in terms of oral functions; moreover, the overlying skin graft presents a very good color and texture harmony aesthetically. This method is a candidate to be an exclusive surgical technique in the repair of total or close to total lip losses in the future.

Chimeric Reverse Temporal Muscle and Pericranial Flap for Double-Layer Closure of Deep Facial Defects.

PURPOSE: Volumetric or multiplane defects of the upper and midface remain a challenge for reconstruction because of limited regional flap options. In this study, the authors harvested the reverse temporalis muscle flap and pericranial flap (RTMP flap) based on the same vascular pedicle, the superficial temporal artery, in a chimeric manner to obtain double-layer closure of deep facial defects. MATERIALS AND METHODS: This study was a prospective case series performed in the Department of Plastic Surgery of Ataturk University (Erzurum, Turkey). The outcomes, including flap survival, postoperative complications, reconstructive success, esthetic appearance, and donor site morbidity, were clinically evaluated. RESULTS: Fourteen patients (10 male and 4 female) with deep defects of the middle third of the face underwent reconstruction using the chimeric RTMP flap. All chimeric RTMP flaps survived without postoperative complications. All defects were successfully repaired and covered with chimeric RTMP flaps. Patients were satisfied with the esthetic results. CONCLUSION: The chimeric RTMP flap is a good reconstruction option and can be used safely for moderate to large 3-dimensional defects of the middle and upper face. Smooth and durable coverage over the bulky muscle flap used to fill the volume defect and a larger flap for larger volume defects can be obtained by including the pericranial segment of the chimeric RTMP flap.

Treatment of Linear Scleroderma (en Coup de Sabre) With Dermal Fat Grafting.

BACKGROUND: Linear scleroderma, also known as "en coup de sabre," is a subtype of localized scleroderma that warrants aesthetic correction because it appears on the forehead region in children. OBJECTIVE: To report dermal fat grafting as a novel and effective surgical treatment option in linear scleroderma. METHODS: Under local anesthesia, a dermal fat graft was successfully placed into a subcutaneous pocket that was prepared underneath the depressed scar. The donor site was closed primarily. RESULTS: No early or late complications developed postoperatively. After 1-year follow-up, the dermal fat graft was viable, the depressed scar was adequately augmented, and a good aesthetic result and patient satisfaction were obtained. CONCLUSION: We believe that dermal fat grafting is a cost-effective option and provides a long-lasting aesthetic outcome in the management of linear scleroderma.