Objective Periarticular defect coverage remains challenging because multi-vector tension forces affect wound tensile strength. This study presents our experience with keystone design perforator island flap (KDPIF) reconstruction of non-oncological periarticular defects surrounded by the zone of injury and describes the expanding versatility of KDPIF reconstruction for periarticular defects. Methods From June 2017 to July 2019, 12 patients aged 8 to 84 years underwent KDPIF reconstruction to cover periarticular defects. All defects resulted from non-oncological causes and were surrounded by the zone of injury. We reviewed the patients’ medical records and clinical photographs to collect and analyze clinical and operative data. Results The defect size ranged from 0.8 × 1.2 to 7 × 10 cm2. The flap size ranged from 1.5 × 3 to 15 × 18 cm2. All flaps survived completely. All patients showed favorable functional outcomes without significant limitation in joint range of motion during the follow-up period (range, 4–12 months). The mean observer scar assessment scale summary score and patient scar assessment scale total score were 17.667 ± 5.921 and 20.167 ± 6.478, respectively. Conclusion KDPIF reconstruction is a simple and effective surgical option for coverage of non-oncological periarticular defects surrounded by the zone of injury.
Rationale: The challenges with reconstruction of penile defects are plenty. In addition, no single and universally accepted reconstructive method exists for penile defect repair. Herein, we present the application of a circumferential penile shaft defect reconstruction using pull-up double-opposing keystone-designed perforator island flaps (KDPIFs) in one patient. This is the first case report of a circumferential penile shaft defect reconstruction using KDPIFs. Patient concerns: A 43-year-old man who injected petroleum jelly into his penis 10 years ago presented with multiple firm nodular mass-like lesions adherent to the overlying skin along the penile shaft. Our urologic surgeon removed the foreign bodies and performed a primary closure with undermining. However, wound dehiscence developed, and skin necrosis was exacerbated 5 days postoperatively. Diagnoses: We performed debridement, and the final post-debridement defect was circumferential (5.5 × 12 cm) from the base of the glans to the midpoint of the penile shaft. Interventions: We covered the defect using pull-up double-opposing KDPIFs (10 × 13 cm each) based on the hot spots of the superficial external pudendal artery perforators on each side from the suprapubic area to the scrotum. Outcomes: The flaps survived perfectly, with no postoperative complications. The patient was satisfied with the final outcome and had no erectile dysfunction or shortening of penile length after a 6-month follow-up. Lessons: We successfully reconstructed a circumferential penile defect with pull-up double-opposing KDPIFs both esthetically and functionally. Our technique can be a good alternative modality for extensive penile defect reconstruction.
Post-traumatic pseudoaneurysms of internal maxillary artery are rare, but may be life-threatening. When arterial damage leads to pseudoaneurysm formation, delayed intractable epistaxis can occur. We report our experience with the diagnosis and management of a ruptured internal maxillary arterial pseudoaneurysm that was discovered preoperatively in a patient with a zygomaticomaxillary complex (ZMC) fracture. He presented to the emergency room with epistaxis, which ceased shortly, and sinus hemorrhage was observed with a fracture of the posterior maxillary wall. The patient was scheduled for open reduction and internal fixation (ORIF) of the ZMC fracture. However, immediately before surgery, uncontrolled epistaxis of unknown origin was observed. Angiography indicated a pseudoaneurysm of the posterior superior alveolar artery. Selective endovascular embolization was performed, and hemostasis was achieved. After radiologic intervention, ORIF was successfully implemented without complications. Our case shows that in patients with a posterior maxillary wall fracture, there is a risk of uncontrolled bleeding in the perioperative period that could be caused by pseudoaneurysms, which should be considered even in the absence of typical symptoms.
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