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Sequela of complex craniomaxillofacial trauma is common. We report a previously undocumented, highly unusual, postfacial trauma presentation of a "nasomalar ball-valve fistula." The clinical presentation was a sharp influx of air into the left malar subcutaneous space with each nasal inspiration, followed by near-complete deflation upon each expiration. We also report a very simple and elegant solution of using a nasal trumpet to completely resolve this problem without the need for additional operation. The final recovery was uneventful. We hope to make all facial surgeons aware of this diagnosis and to remind them to keep this simple device in their armamentarium to address similar issues.
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INTRODUCTION AND IMPORTANCE: Local skin flap techniques, including rhomboid flap, have been developed to reconstruct cutaneous defects. Rhomboid flap advantages include easy design, excellent contour, texture, thickness, color match, and long-term good cosmesis. There is no patient reported outcome study in literature detailing patients' perception of appearance and satisfaction of scar appearance. METHODS: We studied 100 consecutive rhomboid flaps performed in 73 patients by a single surgeon. After at least one year from flap completion, a validated published Patient Scar Assessment Questionnaire (PSAQ) by Durani et al. was completed for each flap. RESULTS: The median age was 73 years, with a range of 21 years-94 years. Gender breakdown was 65 flaps in males and 35 flaps in females. For appearance, there were significantly greater frequency of "very well-matched scar" patients compared to "well-matched scar" patients (p < 0.001). There were no "a little matched" or "poorly matched" patients. For satisfaction of appearance scores, there were significantly greater frequency of "very satisfied" patients compared to "satisfied" patients (p < 0.001). There were no "dissatisfied" or "very dissatisfied" patients. Although size of primary defect was not statistically significant (p 0.071), there was a trend towards better appearance scar match and scar satisfaction for smaller defects. Age was not statistically significant (p 0.086), there was a trend towards better appearance scar match and scar satisfaction among older patients. There was no significant difference in appearance match and satisfaction scores based on the gender (p 0.733). There were no post-operative complications. CONCLUSIONS: Our study confirms, in experienced hands, the long-term patient perception of well-matched scar appearance and scar satisfaction with rhomboid flap technique. A significantly greater frequency of patients were "very satisfied" than "satisfied", with no "dissatisfied" patients. There was no statistically significant difference based on age, gender, and size of the primary defect.
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Cutaneous defects may result from trauma, infection, chronic illness, poor healing, or surgical resections. Traditionally, the concept of the reconstructive ladder suggests that primary closure and skin grafting should be considered first in reconstruction of such defects. However, these techniques may lead to increased likelihood of dehiscence, distortion of key structures, poor cosmetic outcomes, and less-than-total graft acceptance. To overcome these limitations, various local skin flaps and tissue rearrangement techniques have been developed, including rhomboid flap. This flap is quickly and easily designed, does not require any special instruments, and provides excellent contour, texture, thickness, color match, long-term good cosmesis and high patient satisfaction. The following article presents a comprehensive review of rhomboid flaps in the English literature and discusses the indications, applications, and results. Nearly 100 years after it was first described by A.A. Limberg, the time has come to embrace this simple and elegant flap as the preferred method of reconstruction of cutaneous defects of any size, caused by any etiology and on any part of the body.
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INTRODUCTION: and importance: Large cutaneous defects may result from excision of skin malignancies. Typically, skin grafting is used to manage such defects, but the final result may be compromised by inadequate take and poor cosmesis. Accordingly, transposition flaps may be indicated.Case Presentation and clinical discussion: A 93-year-old female presented with a painful, necrotic 12 cm × 12 cm Squamous Cell Cancer of left upper back. She underwent wide excision followed by a rhomboid transposition fasciocutaneous flap. The flap was easily designed, quickly executed, and did not require any special instruments. The overall result was a good cosmetic outcome with no complications. CONCLUSION: Our case outlines successful use of rhomboid flap instead of a more complicated option to reconstruct a very large cutaneous defect. The flap healed with excellent contour, texture, thickness, and color match.
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BACKGROUND: Dog ear, a characteristic bunching up of excess tissue formed during wound closure, is a common unsightly problem in cutaneous surgery. It may present as a cosmetic concern or a source of physical discomfort. Several management techniques have been reported, but it is unclear which approach is the most effective or whether outcomes vary with surgical situations. This report assesses the best practices for dog ear management. METHODS: A systematic literature search was performed. All relevant articles written in English and involving human subjects were included. RESULTS: There were 2028 potentially relevant articles, but only 36 articles met the inclusion criteria. These articles were published in multispecialty journals. They included 23 techniques or case report articles, 6 retrospective and prospective studies, but no clinical trial or randomized control trial. Ten major techniques were identified in the literature. No single technique was proved to be superior in the literature. There was no recommended algorithm in the literature. CONCLUSIONS: Despite there being no single recommended technique to manage dog ear deformities, there is ample evidence to suggest surgeons avoid a pre-planned elliptical design, use a proper skin-conserving design for excision, and carry out a meticulous suture closure as the first steps to prevent dog ears. We discuss the indications for each of the ten techniques and propose an algorithm for dog ear management. Until further research is performed, multispecialty cutaneous surgeons should familiarize themselves with the discussed techniques to provide patients with the best functional and aesthetic results.
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Resection of large cutaneous malignancies may result in substantial skin defects. Often, skin grafting is a first-line option for reconstruction of such defects but may be limited by poor cosmetic outcomes and incomplete graft acceptance. Accordingly, skin flaps, tissue rearrangement techniques, and more complex procedures may be needed. This case report presents the successful use of a rhomboid flap for reconstruction of a 20 × 19 cm2-sized trunk skin defect left after a squamous cell cancer resection. The flap was quickly and easily fashioned, did not require any special instruments, and resulted in a good cosmetic outcome. There were no major wound complications despite postoperative radiation therapy. At 1-year follow-up, the flap healed completely with excellent contour, texture, thickness, color match, and complete patient satisfaction. In the past, rhomboid flaps have been used for small defects. This case is a unique example of a versatile and successful rhomboid flap reconstruction of an extremely large defect, instead of a more complicated reconstructive option.
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INTRODUCTION: Although most tongue lacerations in children can be treated conservatively, accepted indications for suture repair include complex injury, large flaps, and active bleeding. The purpose of this article is to highlight repair of a unique, severe injury pattern in a child. PRESENTATION AND TREATMENT: A 3-year-old boy fell on a cemented floor causing a midline full-thickness laceration through the median fibrous septum, resulting in a bifid tongue. Given the midline location, neurovascular supply was protected, and following surgical repair, the patient enjoyed an uneventful recovery. CONCLUSION: Our case outlines a surgical approach for this unique case of acquired traumatic pediatric bifid tongue, which to our knowledge, has never been reported in the English literature.