Double Trigger Wrist Caused by 2 Flexor Tendon Sheath Giant Cell Tumors.

ABSTRACT: Trigger finger is a relatively common condition affecting the smooth gliding of tendons in the hand. When this entity affects the gliding motion of the wrist, it is termed as trigger wrist. In this article, we report the extremely rare case of a double trigger wrist caused by 2 tendon sheath tumors resulting in 2 trigger points in the motion of the wrist and carpal tunnel syndrome. The patient was managed with surgical excision of the tumors and release of the flexor retinaculum with resolution of symptoms.

The combined profunda artery perforator-gracilis flap for immediate facial reanimation and resurfacing of the radical parotidectomy defect.

BACKGROUND: A radical parotidectomy with facial nerve sacrifice results in facial nerve paralysis as well as a volume and often cutaneous defect. Prior experience with nerve grafting and static suspension has yielded suboptimal results. The present report aims to examine the feasibility and outcomes of a combined free gracilis and profunda artery perforator (PAP) flap from a single donor site can reconstruct these extensive defects and potentially restore dynamic facial reanimation even in the setting of adjuvant radiation. PATIENTS AND METHODS: A retrospective review of 10 patients (6 males and 4 females) was performed from 2016 to 2020 that underwent a combined PAP-gracilis reconstruction of a radical parotidectomy defect. All patients (mean age: 71.3 years; range: 52-83 years) received adjuvant radiation. A chimeric PAP-gracilis flap requiring a single microvascular anastomosis was performed in three patients while the remaining patients underwent a double free flap reconstruction. RESULTS: The gracilis flap was innervated using the facial nerve stump, spinal accessory and massecteric nerve in three patients each. One patient's gracilis was innervated using the hypoglossal nerve. Three patients also underwent nerve grafting of the facial nerve. One patient was taken back to the operating room for a hematoma in the recipient site and there were not flap losses of either the PAP or gracilis flap. Two patients had delayed wound healing of the donor site that healed with conservative management. Average follow-up was 11.1 months (range: 8.1-19.5 months). Six patients were able to achieve dynamic animation while the others obtained a static reconstruction and did not have issues with drooling, eating, or speaking. CONCLUSIONS: Immediate functional muscle transfer can potentially restore dynamic facial reanimation even following radiation. Combining reconstruction using a PAP-gracilis flap addresses the soft tissue deficit and facial paralysis using a single donor site in a single operation.

The Pericranial Flap as a Salvage Procedure in Pediatric Neurosurgical Complications.

ABSTRACT: The pericranium is a vascularized structure that can be used for the treatment of complex scalp and skull defects. It is also utilized as a prophylactic measure to prevent wound complications in high-risk patients. In this study, we looked at the use of the pericranial flap in pediatric patients. A retrospective chart review was done in the American University of Beirut Medical Center from February 2010 to 2020. Ten pediatric patients were identified who required either prophylactic pericranial flap (n  =  3) or for treatment of a chronic draining sinus (n =  7). Patients were followed up for an average of 23 days. There were no cases of infection, hematoma, seroma, or meningitis. Only 1 case developed dehiscence of the skin. It was managed conservatively and healed within 2 weeks. The pericranial flap is a workhorse flap for scalp and skull reconstruction, with no donor site morbidity and thus should always be considered.

Rosai-Dorfman Disease: Cutaneous and Parotid Involvement.

Rosai-Dorfman disease (RDD), also known as sinus histiocytosis with massive lymphadenopathy, is a rare and benign proliferative disease that affects histiocytes. Its etiology remains unclear. Rosai-Dorfman disease primarily affects lymph nodes with many extranodal manifestations present, including cutaneous, pulmonary, ophthalmic, and gastrointestinal. Diagnosis is mainly histologic with the presence of Rosai-Dorfman cells, which demonstrate emperipolesis. We report a case of a 30-year-old man who presented with a facial cutaneous mass and was diagnosed with RDD; he underwent surgical excision. The patient experienced recurrent lesions on the surgical scar and parotid gland as well as the lower back. Treatment consisted of systemic steroids and surgical excision.

Proboscis Lateralis With Heminasal Hypoplasia.

Proboscis Lateralis is a rare congenital anomaly composed of an accessory tubular appendage with possible associated craniofacial anomalies. Computed tomography scan is essential for evaluation of the anomaly and proposing a plan of management. Treatment is complex and should be individualized. The authors present the case of an 18-month old female with left proboscis lateralis associated with left heminasal hypoplasia and coloboma of the left upper eyelid.

Reconstruction of composite leg defects post-war injury.

BACKGROUND: In a high conflict region, war injuries to the distal lower extremity are a major source of large composite defects involving bone and soft tissues. These defects are at the edge between using a single free flap [osteo-(+/-myo) cutaneous] vs double free flap reconstruction (bone and soft tissue). In this paper, we present our experience and outcomes in treating patients with leg war injury reconstructed using a single free fibula flap. METHODS: Fifteen patients with distal leg composite defects secondary to war injuries were treated between January 2015 and March 2016. All patients were reconstructed using single barrel free fibula osteo-(+/-myo)cutaneous flap where single or double skin paddles were used according to the soft tissue defect requiring coverage. RESULTS: There were no cases of total or partial flap loss. Complications were limited to three cases including traumatic fibula fracture, venous congestion with negative findings, and residual soft tissue defect requiring coverage. There were no cases of wound dehiscence or infection. Mean follow-up time was 418.8 days. Mean bone healing time was nine months after which patients were allowed full weight bearing. CONCLUSION: A single barrel free fibula osteo-(+/-myo)cutaneous flap is a valid and reliable tool for reconstruction composite lower extremity defects post-war injury. Adequate planning of fibula flap soft tissue components (skin, muscle) rearrangement is essential for success in such challenging reconstructions.

The Deltopectoral Flap Revisited: The Internal Mammary Artery Perforator Flap.

Pharyngo-esophageal and tracheostomal defects pose a challenge in head and neck reconstruction whenever microanastomosis is extremely difficult in hostile neck that is previously dissected and irradiated. The deltopectoral (DP) flap was initially described as a pedicled flap for such reconstruction with acceptable postoperative results. A major drawback is still that the DP flap is based on 3 perforator vessels leading to a decreased arc of rotation. The DP flap also left contour deformities in the donor site. The internal mammary artery perforator flap was described as a refinement of the deltopectoral flap. It is a pedicled fasciocutaneous flap based on a single perforator, with comparable and reliable blood supply compared with the DP flap, giving it the benefit of having a wide arc of rotation. It is both thin and pliable, with good skin color match and texture. The donor site can be closed primarily with no esthetic deformity and minimal morbidity. The procedure is relatively simple and does not require microvascular expertise. In this report, the authors describe a patient in whom bilateral internal mammary artery perforator flaps were used for subtotal pharyngo-esophageal reconstruction and neck resurfacing. The flaps healed uneventfully bilaterally with no postoperative complications.

The use of the fibula flap in post oncologic reconstruction of long bone in pediatric patients: A retrospective cohort study.

BACKGROUND: Pediatric sarcomas are the most common malignancies of bones in childhood. With advances in adjuvant treatment, limb salvage surgery has become common, increasing the demand of skeletal reconstruction. Traditional practice included bone grafting and transport. Recently, microsurgical tissue transfer in pediatric patients has become a well-accepted practice, with the fibula as an ideal biologic construct for long bone reconstruction. We aim to assess the success rate of this operation, including flap survival, bony union, weight-bearing ambulation, and complications. METHODS: We identified 10 pediatric patients who underwent reconstruction of long bones (femur, humerus, or tibia) with a free fibula flap from January 2015 to January 2020. All patients received neoadjuvant chemotherapy 4 weeks prior to the surgical procedure followed by adjuvant chemotherapy. RESULTS: The average follow-up time was 15 months. We had no partial or total flap loss. Three of our patients passed away in the first post-operative year due to metastatic disease. In the remaining 7 patients, we had two long-term complications. The fibula of one patient did not exhibit hypertrophy, yet weight-bearing ambulation was achieved. The other patient had nonunion proximally that required bone grafting at 8 months post-operatively. After that, the same patient fractured her fibula and required surgical fixation. She was eventually able to achieve weight-bearing ambulation. CONCLUSION: The vascularized fibula flap is a reliable tool for reconstruction in children. Flap survival is similar to that of adults. Complication rate is low compared to that for other forms of reconstruction.

Reliability assessment of the endoscopic examination in patients with allergic rhinitis.

OBJECTIVE: To study if nasal endoscope can be a reliable tool in assessing patients with allergic rhinitis. MATERIALS AND METHODS: A prospective study. Patients who were diagnosed with allergic rhinitis underwent a nasal endoscopic examination performed by two physicians blinded to the scoring of each other. A correlation was made among symptom severity, endoscopic findings, and interrater variability. RESULTS: Ninety patients were included in the study: 34 patients had mild disease and 56 had moderate-to-severe allergic rhinitis according to the Allergic Rhinitis and its Impact on Asthma guidelines. Increases in mucosal edema and bluish discoloration were predictive of the severity of allergic rhinitis disease (p < 0.05). The presence of nasal secretions was not predictive of allergic rhinitis. Interrater reliability was fair for mucosal edema, moderate-to-almost perfect for the rest of the endoscopic findings. CONCLUSION: Nasal endoscopy may reveal signs that are predictive of the severity of allergic rhinitis. A detailed checklist is needed for the nasal endoscopic examination to decrease interrater variability.