Reconstruction of Orbital Floor With Auricular Concha.

Orbital floor fractures of varying sizes commonly occur after orbital injuries and remain a serious challenge. Serious complications of such fractures include enopthalmos, restriction of extraocular movement, and diplopia. There is a dearth of literature that can be applied widely, easily, and successfully in all such situations, and therefore there is no consensus on the treatment protocol of this pathology yet. Autogenous grafts and alloplastic and allogenic materials with a wide variety of advantages and disadvantages have been discussed. The value of preoperative and postoperative ophthalmological examination should be standard of care in all orbital fracture patients. An ideal reconstructed orbital floor fracture should accelerate the restoration of orbital function with acceptable cosmetic results. Management parameters of orbital fractures such as timing of surgery, incision type, and implant materials, though widely discussed, remain controversial. In this study, 55 patients with orbital floor fractures surgically reconstructed with conchal cartilage grafts between 2008 and 2014 were retrospectively evaluated. Complications and long-time follow-up visit results have been reported with clinical and radiographic findings. The aim of this study was to present the authors' clinical experiences of reconstruction of blow-out fractures with auricular conchal graft and to evaluate the other materials available for use.

A rare type of burn injury due to butane gas inhalation.

BACKGROUND: Abusive inhalation of butane gas is becoming a serious public health problem among teenagers and young adult population; however, there has been little reporting on explosion burns associated with abuse of butane cigarette lighter fluid. METHODS: Retrospective study was conducted of 22 patients who were burned in last 2 years in explosion of butane gas, a flammable, odorless, and colorless aliphatic hydrocarbon. RESULTS: Details of sociodemographic profile of the patients, any underlying psychiatric illness, alcohol abuse, depth of burn injury, any associated injury, duration of hospitalization, and percentage of burned area were recorded and analyzed. CONCLUSION: All of the patients were young men, and most had superficial burn injury. Hospital stay ranged from 0 to 11 days. All of the patients were treated with conservative management.

A New Surgical Approach for Tessier No. 4 Facial Cleft Reconstruction: Lip-Rescue Flap.

Craniofacial clefts are rare, severe challenges for surgeons about which there is limited literature. Tessier Number 4 (No. 4) clefts are one of the most complex craniofacial anomalies and present difficulties in surgical treatment. The most-common deformities associated with Tessier No. 4 clefts are displacements of the lower eyelids, medial canthus, and ala and decreased distance between the lower eyelids and lips. In surgery to correct these deformities, the greatest challenges are the design and the placement of the landmarks and incisions. Because of its relative rarity and wide range of severity, no definitive operative methods have been accepted for Tessier No. 4 facial cleft. The present study presents a new lip-rescue flap technique as an alternative approach for reconstructing Tessier No. 4 facial clefts.

Pincer Flap for Reconstruction of Nasal Tip Defects.

INTRODUCTION: Reconstruction of the nasal tip defects is challenging because of variable contours of the region and the unique texture, thickness, color, and limited amount of available skin. There are several well-known local flaps for this purpose. Unfortunately, most of these flaps are suitable for small sized defects up to 2 cm in diameter. In this study, the authors are presenting a new flap for reconstruction of nasal tip and supratip defects larger than 2 cm in diameter. METHODS: Pincer flap was used for reconstruction of nasal tip defects in 12 patients, between 2011 and 2014. The mean age was 67 (43-88). All patients had a basal cell carcinoma. Defects were located at the central nasal, lateral nasal, and supratip areas. All tumors were excised with safe margins. After the excision, defects were reconstructed with pincer flap in the same session. RESULTS: The mean follow-up period was 11 (6-18) months. There was not any flap loss. Infection and venous congestion was observed in 2 patients but the patient did not require any further surgical intervention, and healed with local and systemic antibiotherapy. No recurrence occurred and the outcome was aesthetically favorable. CONCLUSIONS: The authors concluded that pincer flap is reliable and may provide a single-stage reconstruction for the nasal tip defects larger than 2 cm and up to 3 cm in diameter.

Intranasal Extramucosal Access: A New Access for Lateral Osteotomy in Open Rhinoplasty.

BACKGROUND AND OBJECTIVE: Different accesses have been used to perform lateral osteotomies in rhinoplasty. All of them have some disadvantages. The aim of this paper was to report a new access to overcome drawbacks of the other techniques in lateral osteotomy during open rhinoplasty. METHODS: An anatomical study was designed to search possibility of intranasal extramucosal access (open sky access) for the lateral osteotomy in open rhinoplasty. It was performed directly on the lateral wall of piriform aperture, and then possible advantages of this technique were investigated. Five fixed cadavers were used for this purpose. No drawbacks were observed during procedure in cadavers. Then the same procedure was performed in 23 consecutive rhinoplasty patients. Nineteen operations were primary and 4 operations were secondary. Median oblique osteotomies were added to the procedure in all patients. The mean follow-up was 17 months. RESULTS: Intranasal extramucosal access during lateral osteotomy was easily performed in all patients. Hemorrhage due to angular vessel injury was not occurred during intraoperative period. Edema and ecchymosis was minimal. Intranasal examination did not show any sign for nasal mucosal tearing in all patients. Residual bone spurs or bone irregularities were not observed in any patients. CONCLUSION: Intranasal extramucosal access that produces precise, predictable, and reproducible aesthetic and functional results could also provide better exposure during lateral osteotomy. Additionally, open sky access minimizes scars because it does not need additional incisions on the skin and mucosa. Protection of the internal periosteum of the nasal bones may be the main advantages of this technique.

Estimated beginning time of local anesthesia effectiveness in forced cold air application: A preliminary study.

BACKGROUND: The literature has reported that forced cold air anesthesia decreases the discomfort effect of various laser therapies. The aim of this preliminary study was to determine the average beginning time of the local anesthetic effect of the forced cold air application when it is applied to all body surfaces except the face. MATERIALS AND METHODS: A total of 52 participants (26 females and 26 males) were included in this study. During application of the forced cold air, the beginning time of local anesthesia effectiveness for each volunteer was determined by giving painful stimuli. The results were then analyzed statistically. RESULTS: The mean beginning time value of the local anesthesia was 52.88 (ranging between 30 and 60) seconds in the female group and 56.34 (ranging between 30 and 60) seconds in the male group. The mean beginning time value of the local anesthesia was 54.61 (ranging between 30 and 60) seconds in both genders. There was no statistical difference between the two groups (Z = - 0.834, p = 0.404). CONCLUSION: Forced cold air anesthesia-which is a quick, safe, cost-effective, and practical local anesthesia method-seems to be useful and effective when used alone in laser treatment.

Comparison of Subciliary Approaches in Orbito-Zygomatic Fractures: Skin Flap Versus Skin-Muscle Flap.

BACKGROUND: Because of the complications of classical subciliary incision, some modified subciliary approaches have been described in recent literature. OBJECTIVES: The aim of this study was to compare 2 commonly used subciliary approaches according to development of postoperative complications (scar formation, and ectropion). MATERIALS AND METHODS: Ninety patients were included in this retrospective study. Subciliary skin flap technique (SF group) was performed to 39 patients, while the others were operated by using skin-muscle (stepped) flap technique (SMF group). Fitzpatrick skin types, genders, ages, scar scores, and ectropion scores of the patients also were recorded. RESULTS: The mean age of the patients was 39.3 (18-99) years, and the mean follow-up period was 2.1 (1-6) years. Fitzpatrick skin-type levels were between 2 and 4 (median = 3). No difference was found between 2 groups in terms of age, follow-up period, and Fitzpatrick skin-type levels. However, the scar values of the SMF group were significantly lower than the SF group statistically. Also, there was no significant difference between males and females in SF and SMF groups in terms of scar and ectropion formation. On the other hand, scar values were lower in SMF groups rather than SF group in males. Although ectropion values were not different between SF and SMF groups in females, ectropion values of SMF group were significantly lower than SF group in males statistically. CONCLUSION: Subciliary skin-muscle (stepped) flap technique can be more reliable than subciliary skin flap technique for approach to orbitozygomatic fractures.

The Versatile Facial Artery Perforator-Based Nasolabial Flap in Midface Reconstruction.

INTRODUCTION: Defects in the lower two thirds of the face occur due to trauma, tumoral masses, or infections. In this study, repairs of various defects located in the midface using facial artery perforator-based nasolabial flaps are presented. PATIENTS AND METHODS: Between January 2009 and June 2013, 15 patients with defects in the lower two thirds of the face or the intraoral region underwent repairs with facial artery perforator-based nasolabial flaps. The etiology was malignant skin tumor excisions in 11 patients, infection in 2 patients, and trauma in 2 patients. Among the patients, 10 were male and 5 were female. Their mean age was 65.1 (range: 20-86) years. The mean duration of follow-up was 14 (7-24) months. The defects were located at the upper lip, cheek, lower lip, intraoral region, and the nasal area. The size of the defects varied between 10 × 10 mm and 40 × 50 mm. All the flaps were prepared as perforator flaps. The flap donor area was primarily closed. RESULTS: No partial or total flap loss was observed in any of the flaps. The flap donor areas healed without problem. Full patient satisfaction was achieved both aesthetically and functionally. CONCLUSION: The nasolabial perforator flap has certain advantages such as the 1-stage application, repair using a similar tissue, a wider rotation arc around the pedicle compared to the other regional flaps, and the primary closure of the donor area. Based on these characteristics, it is an ideal alternative for the repairs of the defects located in the lower two thirds of the face or the intraoral region.

Combination of rhomboid flap and double Z-plasty technique for reconstruction of palmar and dorsal web space burn contractures.

BACKGROUND: Web space contractures after a burn can cause severe impairments in hand function along with esthetic deformities. In this study we present our experience with the combined treatment technique consisted of rhomboid flap and double Z-plasty for palmar and dorsal web space contractures. MATERIALS AND METHODS: Combined rhomboid flap and double Z-plasty was performed in eight patients with eleven web space contractures occurred after burn. The average follow-up was 10.9 months. RESULTS: The average age of 8 patients was 16.3 years. The average duration of burn contractures was 6 years (range 1-13 years). The right third web of the patients was the most common contracted web space. In the postoperative period hematoma, infection, partial or total flap loss was not observed in any patient. Web and hand function and esthetic appearance of web spaces were satisfactory in the late postoperative period. CONCLUSION: Rhomboid flap combined with a double Z-plasty technique was an effective choice for the treatment of palmar and dorsal web space contracture after burn.

Fujimori gate flap: an old flap for reconstruction of lower lip defects due to lower lip carcinoma resection.

OBJECTIVES: This study aims to present our clinic experiences on the Fujimori gate flap used for reconstruction of lower lip defect due to lower lip carcinoma. PATIENTS AND METHODS: This retrospective study included 19 patients (7 females, 12 males; mean age 60.3 years; range 41 to 79 years) who underwent reconstruction with the Fujimori-gate flap between January 2006 and March 2011. Demographic features of all patients and postoperative long-term functional and aesthetic results were reviewed. RESULTS: The mean size of the defects was 34.2 mm (range, 10 to 60 mm). Totally 27 flaps were elevated. No complication was observed after surgical procedure. In the long-term, nine patients underwent minor revisions. None of the patients showed local recurrence. CONCLUSION: Fujimori gate flap may be used for the reconstruction of the soft tissue loss after tumor surgery at lower lip.

Correction of hyperpigmented palmar grafts with full-thickness skin grafts from the lateral aspect of the foot.

The palmar surface of the hand possesses special features when compared with the hair-bearing parts of the body. The same quality of skin has to be used in reconstruction of the palmar skin defects to restore normal function. The lateral aspect of the foot has similar features with the palmar region histologically and can be used for palmar reconstruction. Seventeen patients who had hyperpigmentation after skin graft in the palmar region were treated. Scar contracture was combined in seven patients. The hyperpigmented grafts were excised and then the defects were full-thickness skin grafted from the lateral aspect of the foot. The mean follow-up period was 13.7 (4-22) months. Engraftment was successful in 16 patients, but one failed due to haematoma. The colour of the graft was initially reddish, and then became similar to the palmar area. The donor site healed without any problem within 3 weeks. At follow-up these grafts had good colour and texture match with adjacent palmar skin. There was no hyperpigmentation. Minimal marginal scarring and scar hypertrophy occurred in four patients (24%). The skin of the lateral aspect of the foot is a good choice for palmar skin defects, because of the similarities in their characteristics. Results are acceptable in terms of minimal recurrence of scar contracture, no hyperpigmentation, adequate colour and texture match, and minimal marginal scarring and scar hypertrophy.

Treatment of hyperdynamic nasal tip ptosis in open rhinoplasty: using the anatomic relationship between the depressor septi nasi muscle and the dermocartilaginous ligament.

BACKGROUND: Smiling causes a deformity in some rhinoplasty patients that includes drooping of the nasal tip, elevation and shortening of the upper lip, and increased maxillary gingival show. The depressor septi muscle leads this deformity. The dermocartilaginous ligament originates from the fascia of the upper third of the nose and extends down to the medial crus, merging into the depressor septi muscle. METHODS: In this study, 100 primary rhinoplasty patients were studied for hyperdynamic nasal tip ptosis. Of these patients, 36 had hyperdynamic nasal tip ptosis due to hyperactive depressor septi nasi muscle. The dermocartilaginous ligament was used as a guide to reach the depressor septi muscle in open rhinoplasty. Muscle excision was performed just below the footplates of the medial crura. A strong columellar strut graft was placed between the medial crura to avoid narrowing of the columellar width resulting from tissue excision and to withstand activation of depressor septi muscle remnants. RESULTS: No complications such as infection or hematoma occurred in the early postoperative period. The technique corrected the hyperdynamic nasal tip ptosis, increased upper lip length, and decreased gingival show when patients smiled. There was no narrowing of the columellar width. No depression in the columellar-labial junction due to distal resection of the depressor septi muscle was observed. CONCLUSION: The dermocartilaginous ligament can be used as a reliable guide to reach the depressor septi muscle in open rhinoplasty. Therefore, the hyperactive depressor septi muscle can be definitively identified and treated without an intraoral approach. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

A case of syngnathia, cleft palate and hypospadias: an isolated case or syndromic syngnathism?

Syngnathia occurs when an ectopic membrane forms a fibrous or bony adhesion between the maxillary and mandibular alveolar processes. A case of congenital syngnathia is presented.

Importance of the levator labii alaeque nasi muscle in dorsal septal deviations.

Deviated cartilages structures of the nose can be affected by nasal muscles, and deviation becomes conspicuous when the patient smiles. This condition depends on activity of nasal muscles, particularly the levator labii alaeque nasi muscle. A total of 124 septorhinoplasty operations were performed to correct dorsal concave septal deviation between 2005 and 2009 years. The 70 women and 54 men included in the study had an average age of 28 years. The average follow-up period was 12 months. Open septorhinoplasty was preferred in all cases. The medial part of the levator labii alaeque nasi muscle was extensively dissected from the lateral crus and surrounding tissues. The lateral crura of the alar cartilages were separated from the upper lateral cartilages in the scroll area. The dorsal septal deviation was corrected by combination of bilateral spreader grafts, which reinforced cartilage with horizontal control sutures. Early postoperative period was uneventful. Nasal obstruction was reduced after surgery, and significant subjective postoperative improvements were observed in all patients. Comparison of preoperative and postoperative photographs demonstrated improved dorsal nasal contour. Revision operation was performed in 3 cases. The corrected septal cartilage was in a good position in all revised cases; therefore, septal surgery was not performed in the revision operations. In conclusion, surgical disruption of the anatomic relationship between the muscle with the dorsal septal cartilage and reinforcement of the dorsal septal cartilage with spreader grafts and horizontal control sutures can decrease risk of recurrence.

Topographical anatomy of the dorsal branch of the ulnar nerve and artery: a cadaver study.

PURPOSE: The surgical anatomy of the dorsal branch of the ulnar nerve and artery on the dorsal aspect of the hand is important in design of neurocutaneous flaps for reconstructive surgery and serves as a donor site for nerve grafts. In this study, the course, location, and diameter of the dorsal branches of the ulnar nerve and artery were studied from anatomical and reconstructive perspectives. METHODS: Upper limbs of 14 (7 left and 7 right) and 22 formalin-preserved adult cadavers (15 left and 7 right) were dissected in two different centers. RESULTS: The diameters of the ulnar nerve, artery, and their dorsal branches were measured at selected reference points. The distances to specific anatomical landmarks were also measured, during their courses from the proximal forearm towards the middle phalanges of the 4th and 5th fingers. CONCLUSIONS: Our data may facilitate the design of neurocutaneous flaps nourished from the dorsal branches of the ulnar nerve and artery, and may aid in the harvesting of nerve grafts from the dorsal branch of the ulnar nerve, and provide a safe surgical approach to the dorsum of the hand.

Upper lip augmentation with double-row subcutaneous pedicled V-Y flaps in Möbius syndrome.

Treatment of open-mouth deformity and augmentation of the upper lip were performed using a combination of double-row V-Y mucosal advancement flaps and a V-Y skin advancement flap in 2 cases with Möbius syndrome. The mucosal V-Y advancement flaps were consisted for 2 rows of flaps. The first row was placed near the labial sulcus, including 3 V-Y advancement flaps. These flaps equally provided 3 directional augmentation for each segment of the upper lip. Second row V-Y mucosal advancement flap was used for the augmentation of the vermilion tubercle. In our cases, V-Y advancement flaps were used as subcutaneous based flaps unlike other distally based V-Y flap techniques for the upper lip. Postoperative complications such as scar formation, sensation problems, severe pain, and edema were decreased because of subcutaneous pedicled V-Y flaps. In addition, the relationship between mucosa and orbicularis oris muscle, which is responsible for the fine balance of the vermilion, was maintained with subcutaneous-based flaps. The skin V-Y advancement flap was used both to lengthen the upper lip and to create philtral columns on the upper lip.

[Repair of soft tissue defects of the nose]. / Burun yumusak doku defektlerinin onarimi.

OBJECTIVES: Soft tissue defects of the nose resulting from lesions may cause aesthetic and functional problems if they are not properly repaired. PATIENTS AND METHODS: In this study, a retrospective analysis was conducted of 104 patients (59 females, 45 males; mean age 53 years; range 33 to 89 years) who were operated in our clinic between November 2005 and July 2009. Nasal soft tissue defects resulting from excision were closed with a primer closure for 16 patients, a procerius muscle skin flap for 11 patients, a nasolabial flap for 26 patients, a dorsal nasal flap for 12 patients, a forehead flap for three patients, an orbicularis oculi muscle skin flap for three patients, a V-Y advancement flap for seven patients, a bilateral V-Y advancement flap for one patient, a Banner flap for nine patients, a bilobe flap for eight patients, an interpolation flap for two patients, a skin graft for 10 patients. RESULTS: We did not observe any occurances of flap necrosis in any of the patients being treated with skin and muscle skin flaps. After we recognised that two patients' excision margins were positive, re-excision was performed on them. Tumor recurrence was observed in one patient, and was repaired with skin graft. CONCLUSION: In this study, we present our successful results in the treatment of soft tissue defects. Reconstructive strategy should be considered from simple to more complex planning. Skin flaps should be elevated according to nasal aesthetic units. Which reconstructive technique to employ should be decided with respect to the localization of the nasal defect.

Cartilage Z plasty on lateral crus for treatment of alar cartilage malposition.

BACKGROUND: Alar cartilage malposition is an anatomical variation. Axis of the lateral crus lies cephalically and can be parallel to the cephalic septum. The characterised findings of the malposition are broad and bulbous nasal tip, abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities and associated external valvular incompetence. This article presents a new technique for the repositioning of the lateral crus in this article. METHODS: Open rhinoplasty was conducted. A cartilage Z plasty was performed on the lateral crus of the alar cartilage to treat for malposition. The 14 women and 8 men included in the study had an average age of 27 years (range, 18-46 years). The average follow-up period was 12 months (range, 4-20 months). RESULTS: Alar cartilage malposition was successfully corrected in patients with aesthetic and functional improvements. CONCLUSIONS: Cartilage Z plasty can effectively correct alar cartilage malposition. Advantages of this technique can be listed as follows: it does not require extra graft material and protects the lateral crural complex; it does not disrupt movements of the alar muscles and can also serve to adjust projection of the nasal tip.