Ricardo Nascimento

Reconstruction of a near total ear amputation with a neurosensorial radial forearm free flap prelaminated with porous polyethylene implant and delay procedure

When an auricular defect is caused by high‐energy trauma that causes damage to the surrounding tissues, the patient may be not a candidate for reconstruction with local flaps and free tissue transfer may be necessary. Here we present a case of total auricular reconstruction in a 27 year‐old man who had total loss of the left ear and traumatized temporal skin and fascia. A radial forearm flap prelaminated by a porous polyethylene implant was employed. A “printed” ear made of silicone, based on the patients CT‐scan of the contralateral ear, was used for intraoperative molding of the future reconstruction. Prolonged prelamination time and surgical delay (three months) were performed to reduce edema, distortion and loss of definition of the framework after revascularization. After subsequent integration and neovascularization of the added tissue, the prelaminated flap was transferred. Flap reinnervation was also performed by direct coaption of the great auricular nerve to the lateral antebrachial cutaneous nerve. The flap fully survived and there were no complications in the early postoperative period. Between 3 and 6 months, the patient returned to normal ranges in terms of warmth and cold, and recovered the discriminative facial sensibility. After one year the auricular reconstruction was intact and satisfactory aesthetic results were achieved. This method may offer a satisfactory solution for a difficult problem and may be considered for acquired total ear defects.

The Retromolar Trigone: Anatomy, Cancer Treatment Modalities, Reconstruction, and a Classification System

Background:Retromolar trigone (RMT) tumors are rare and aggressive malignancies, spreading rapidly into surrounding structures. In reviewing the literature, there is lack of information and quality evidence pertaining to their management and high heterogeneity in treatment modalities. Methods:A systematic Medline search was performed to gather all reports of articles related to retromolar trigone in tle last 10 years (2005–2015). Papers were excluded if they were related to oral cavity cancer but not specific for the RMT. Results:Results were divided into 5 sections: anatomy and lymphatic drainage; etiology and diagnosis; cancer treatment modalities; reconstructive options; proposal of a classifications system. A clinical patient exemplification was also included. Various treatment modalities have been tried in the past including surgery, radiotherapy, and combination therapy using chemoradiation. All these modalities have intrinsic risks. There is also controversy regarding the extent of surgery. Reconstructive options differ with the size of the defects. The ability of the propeller lingual flap to rotate any angle up to 180 degrees allows it to reconstruct small-to-medium sized defects. If bulkier reconstructions are needed to separate oral and nasal cavities, a free flap (radial forearm, anterolateral thigh, medial sural) should be planned. Conclusions:In view of the rarity of the tumor and heterogeneity of treatment, there is limited information available pertaining to retromolar trigone tumors. A better understanding of RMT amatomy, cancer treatment modalities, and reconstructive options can improve the surgeon decision capacity and clinical results, when dealing with such uncommon and challenging tumors.

Thermographic analysis of facially burned patients

37 35 blood flow and surface temperature. We have analyzed a 24 year-old male patient with severe cosmetic and functional facial burn sequelae (Fig. 1). He was submitted to several reconstructive operations, including skin grafts (for both superior and inferior eyelids, frontal and right zygomatic regions, as well as nasal dorsum) and use of dermal regeneration templates – Integra (lower lip, mental region, neck and both hands) in order to improve his appearance, but a disfigured face remains. The patient does not consider facial transplantation at the present time, and other options should be investigated. Thermographic measurements were taken 5 years after injury using a FLIR SC7000 thermography camera (FLIR Systems, Wilsonville, OR, USA) with a Hot Metal colored lens filter which was previous configured to a 30–40 8C temperature range. The subject sat on a chair at a distance of 1.5 m from the camera and was asked to perform four facial expressions: facial expression at rest, with eyes closed, eyes wide open and smile. Data management was performed with Altair 5.91.010 software (FLIR Systems, Wilsonville, OR, USA). An analysis mask was established over the facial areas of interest: 1, right forehead; 2, left forehead; 3, right orbit; 4, left orbit; 5, nose; 6, right labial commissure; 7, left labial commissure; 8, mouth (SDC1). For each area the mean temperature and its standard deviation were calculated, as well as the maximum and minimum values (Table 1).

The Freestyle Facial Artery Perforator Flap for Reconstruction of Simultaneous Periorbital and Cheek Defects.

The reconstruction of defects involving the nasolabial, paranasal, and periorbital regions may be challenging, because they often involve more than one facial aesthetic unit, and can lead to functional problems. An average of 5 facial artery perforators of caliber >0.5 mm can be found above the mandible. A reference point for the location of the most constantly encountered perforator was suggested as being 1.5 cm lateral to the oral commissure, and at its same level in height or slightly inferior to the commissure. Based on injection studies, it is known that these perforators can supply an average area of 8 cm. The authors have extended the use of the freestyle perforator flap in a 87-year-old woman presented with an advanced melanoma of the paranasal area and nasolabial region (Breslow depth: 9 mm; Clark level V). Complete resection of the lesion with 3 cm oncological margins was performed. One-stage reconstruction with superior cosmetic results was achieved. The need for a perforator dissection is not necessarily a drawback, and classic concerns should be abandoned. The face is highly vascularized, and flap congestion is a rare event, usually a consequence of excessive pedicle trimming. Although technically more demanding, it should become one of the first reconstructive options when dealing with similar defects, if our results are confirmed in larger series.

A Novel System for Assessing Facial Muscle Movements: The Facegram 3D

To the Editor: After we have described our previous method, a novel system capable of quantitatively assessing facial muscle movements was developed and is here presented. It automatically describes a set of morphological measurements and uses depth cameras together with advanced computer vision techniques, to perform detailed 3-dimensional (3D) characterization (Figure 1). The system is simple and of great clinical value. In a clinical setup, the clinician places ink dots/markers on the face of the subject identifying anatomical landmarks whose movement should be characterized. The face is recorded by the camera while performing prespecified movements. The analysis results are organized as an innovative and standard medical tool named FACEGRAM-3D. Given the complexity of facial musculature, it is not feasible to collapse the spatiotemporal analysis into a single plot. Instead, it aggregates a set of plots and measures (Supplemental Digital Content–1 [SDC1] available in the online version of the article). The report is organized in 3 information blocks: subject’s data, static analysis, and dynamic analysis. Patient’s information, such as name/age/sex/date are presented at the top, as well as a representative frame at each phase of the movement (with its duration in seconds, Figure 2). The quantitative analysis is divided into 2 different categories: static and dynamic. The components regarding static analysis are the 3D positions of each anatomical point at rest and at maximum extension, a table with maximum extensions for each marker and a symmetry index. This metric, between 0 and 1, is intended to provide information about the relative position of points at rest for each associated pair of anatomical landmarks (in the case of smile: R/L commissures and L/R midpoints). 753227 SRIXXX10.1177/1553350617753227Surgical InnovationHorta et al letter2018

Reconstruction of a postraumatic radial club hand with a free fibular osteoseptocutaneous flap and Sauve-Kapandji procedure-A case report.

Radial club hand may be congenital or acquired; radial deviation of the hand is usually found, associated with palmar flexion–pronation and treatment of severe forms of radial club hand is often difficult. Here we present a case of reconstruction of a severe postraumatic radial club hand with a free fibular osteoseptocutaneous flap and Sauve–Kapandji procedure in a 28‐year‐old man. The patient had a radial deviation of the wrist and right upper limb shortening as a result of an infected pseudarthrosis of the radius. This deformity was reconstructed with a free fibular osteoseptocutaneous flap associated to arthrodesis of the distal radioulnar joint and an ulnar resection osteotomy proximal to the arthrodesis in order to restore rotation of the forearm (Sauvé–Kapandji procedure). The flap fully survived and no complications were seen in the early postoperative period at both recipient and donor sites. Radius alignment was restored. At 5‐month follow‐up, the skeleton was healed. There was minimal osteopenia at the distal radial segment. Wrist extension was 48 degrees, flexion 24 degrees, and pronation–supination was 58–0–48 degrees, with full finger flexion. The patient could hold a 4 kg dumbbell with the elbow flexed without discomfort. His DASH score—Disabilities of the Arm, Shoulder, and Hand Questionnaire was 15.83. Combined free fibular osteoseptocutaneous flap and Sauve–Kapandji procedure may be considered in severe forms of postraumatic radial club hand, however, further data are necessary.

The Reverse Homodigital Flap Based on the Dorsal Branch of the Digital Artery for Reconstruction of Acquired Clinodactyly

Clinodactyly, the angulation of a digit in the anteroposterior plane, is often due to a longitudinal epiphyseal bracket on the radial side of the middle phalanx of the little finger. The curvature rarely limits function and surgery is usually performed to improve cosmesis. Treatment options include observation, osteotomy, and epiphyseal bar resection. On the contrary, acquired clinodactyly may be a consequence of trauma or abnormal scarring. Those with functional limitations, typically associated with angulation greater than 25 degrees, may benefit from surgical correction. The ideal treatment should include scar tissue removal and reconstruction of any secondary soft tissue defect. Some studies1–4 have shown that elevation of a reversedflow, homodigital dorsal adipofascial turnover flap is possible, because dorsal cutaneous perforator branches from the proper palmar digital artery supply the dorsum of the finger. There are two constant and symmetric (radial and ulnar) branches over both the proximal and middle phalanges

Correction of Residual Static and Dynamic Labial Deviations in a Paralyzed Face After Free Gracilis Muscle Transplantation.

Free muscle flap transfer is currently the procedure of choice for longstanding facial paralysis to restore symmetry both at rest and when smiling. However, movements obtained are generally localized, unidirectional, and philtrum centralization and lower lip movement is not proportionally achieved. The stability of free flap insertion at the lips also interferes with the results, as gradual disinsertion and shifting of the nasolabial fold can be caused by repetitive movements. Asymmetry of smile can also be caused by lip depressor inactivity due to marginal mandibular paralysis, and both dynamic and static procedures are often required after dynamic reanimation. Here, the authors report a technical refinement that can be used even years after facial reanimation, using concealed scars and with minimal morbidity for correction of static and dynamic labial deviations from the midline. Placement of a transfixed tendon graft in C-fashion tendon graft between the gracilis free flap and the orbicularis oris of the upper and lower lip on the nonparalyzed side allows the forces from muscle contraction to be transferred to the philtrum and lower lip. It allows correction of static and dynamic labial deviations from the midline, reducing rates of inadequate fixation and partial or total disinsertion of the muscle flap in the buccal region.

Pierced finger ring: A rare case of a neglected burned hand.

Neglected hand burns are common in developing countries but rare in developed countries due to easier access to healthcare. They can lead to severe deformities compromising hand function. The authors present an extreme case of a neglected chemical burn of the hand. The purpose of this article was to alert healthcare professionals and also the mass media to the need for burn care education of the general population.

The Ultrasound-Guided Fat Transplantation

To the Editor: Fat transplantation is currently a widely-used procedure in plastic and reconstructive surgery. Despite the guidelines and technical principles are well known, it remains a “blind” method with unpredictable and sometimes inconsistent results. On sonograms, the fat in normal breast parenchyma is hypoechoic, fibrous tissue is echogenic, and glandular tissue is intermediate in echogenicity, and give that, theoretically once injected fat will not offer great contrast with the surrounding tissues. We have investigated the feasibility of ultrasound-assisted fat transplantation and high-quality breast sonograms were obtained using 7.5 to 10 MHz linear transducers, imaging the infiltrated area within the transducer focal zone. This technique was used in 2 patients with different clinical situations: