Case 1
Periorbital Trauma With Enucleation
A 27-year-old sustains a knife injury to the eye with soft tissue, globe and bone injuries.
Objective 1: The candidate can diagnose the associated fracture pattern(s)
- Question 1: On the basis of this representative CT, what facial fracture patterns can you identify.
- Frontal sinus fracture
- Supraorbital rim fracture
- Zygoma fracture
- Lateral orbital wall fracture
- Maxillary wall fracture
- Possible Lefort II fracture (cannot assess on this image)
Objective II: The candidate can describe potential flaps for orbital reconstruction
- Question II: The patient sustained an intracranial injury to the frontal lobes that disrupted the dura with an associated carotid artery injury. The globe was unsalvageable and was enucleated. The patient was left with a large communication between the cranial fossa and globe. What flaps could you use to close this communication?
- Pericranial flap
- Temporalis flap
- Free tissue transfer
- Free anterolateral thigh flap (ALT) fascia
- Radial forearm
- Free muscle transfer, etc.
Objective 3: The candidate can order appropriate imaging to plan for the reconstruction
- Question 3: With the multiple stab injuries to the face and neck, what test would you order to help in your flap selection?
- Angiogram
- CT angiogram
- MR angiogram
Objective 4: The candidate can describe the elevation and inset of a temporalis flap
- Question 4: There is damage to the ipsilateral internal carotid artery but the blood supply to the temporalis is preserved. Describe the blood supply and elevation of the temporalis muscle flap.
- Anterior and posterior deep temporal arteries of internal maxillary artery
- Scalp incision along temporalis insertion
- Flap designed with pericranial extension
- Elevate pericranium with freer and continue inferiorly raising temporalis muscle while protecting deep temporal arteries
- Consider zygomatic osteotomy to facilitate inset
- Secure flap to dura
Case 2
Upper Lip Trauma in Young Patient
Objective 1: The candidate can describe an approach to the reconstruction of the upper lip
- Question 1: A young patient is attacked by a dog and is referred for an upper lip tissue deficiency. How do you classify a lip defect?
- Divide lip by anatomic subunits: philtrum, lateral
- Full thickness versus partial thickness
- Divide lip by thirds
- Red lip versus white lip
- Any of above appropriate
Objective 2: The candidate can describe the lip defect based on the approach used above
- Question 2: How would you classify this patient’s defect?
- Full thickness loss
- Lateral lip loss and partial philtrum loss
- Complete loss of vermilion and white roll, partial loss of white lip
- Loss comprising 1/2 of upper lip
Objective 3. The candidate can describe an approach to the reconstruction of the defect
- Question 3: What are the reconstructive options for this defect?
- Combined primary closure with secondary intention healing
- Full-thickness grafting
- Flap reconstruction
Objective 4: The candidate can describe the arterial anatomy and an approach to the lip switch flap
- Question 4: What is the blood supply to an inferior lip flap? What is your approach to the Abbe or lip switch flap?
- Right inferior labial artery branch of facial artery
- Mark the vermillion border on both the upper and lower lips along with the red line and white roll
- If possible, place donor site midline
- Design a flap one half the width of the defect, with a vertical height of the defect and the pedicle toward the side of the defect
- Identify the artery with Doppler pen or based on landmarks at junction of red and white lips, deep to orbicularis oris (between mucosa and muscle)
- Identify and ligate the medial inferior labial artery
- Rotate and inset the flap in a layered fashion aligning the vermilion border and red line
- Plan for pedicle division after 2 weeks
- Prior to division clamp the pedicle to ensure perfusion is adequate
- If inadequate perfusion delay division as required