congenital Alar defect and its reconstruction

Congenital anomalies of the nose are very rare and include the bifid nose, complete absence of the nose, and unilateral absence of the nose

A 23-year-old medical school student was diagnosed with a rare congenital nasal anomaly including left alar full-thickness defect

Under general anesthesia, a posteroinferiorly based V-Y flap was selected to cover the outer surface. To make the inner lining, another anteroinferiorly based V-Y flap from the internal coverage tissue was elevated, including alar cartilages remnants and so ft tissues around it These two V- Yflaps were called double-opposing V- Yflaps. To support the alar wing, a cartilaginous graft was inserted taken from the anterior septal edge

The treatments of the nasal alar defects resulting from oncological surgery and those from congenital anomalies significantly differ. The expectations of the patients from the surgery are higher in the second situation than in the first one. A technique using minimal donor site morbidity should be searched

Burn contracture reconstruction by delayed skin grafting

Burn contractures may change according to the defect after release operation depending on the contracture's localization. The larger the joint, the larger the flap requirements following the contracture release. Generally, flexor surfaces of the body include some important neurovascular structures, and covering the area with a thick and uncontractable tissue following the release operation is of importance. This can be best done by a proper flap selection. However, flap elevation is not devoid of morbidity, and the morbidity changes with the size of the flap. Furthermore, a patient may require many flaps from time to time to treat such a problem, and at the same time the patient may not have enough flap donor site.This paper presents nine burn contractures treated with split-thickness skin grafting after 3 weeks following contracture release. During this interim 3-week period, the granulation tissue filled the defect up to the level of the adjacent healthy skin. A nonadherent dressing material was applied to the wound to prevent pain and hemorrhage during the waiting period. In the second operation, only the superficial unhealthy granulation tissue was removed and then the defect was covered with split-thickness skin graft, without any complications. The obtained results were as excellent as can be obtained from a flap transfer

Blepharoptosis following surgery for facial paralysis

Although various well-known forms of blepharoptosis have been reported, there is no report arguing blepharoptosis following the surgery for facial paralysis. A 40-year-old woman with unilateral facial paralysis secondary to mastoidectomy 20 years ago was admitted with her left upper eyelid ptosis. It was found that a free muscle grafting with tendon had been done to treat the complication. A Z-plasty was done to elongate the short tendon by 7 mm under general anesthesia. For reconstructing the mouth corner, a superiorly based sternocleidomastoid muscle flap was transferred after 3 months of the Z plasty on tendon. The ptosis disappeared soon after Z-plasty surgery on the tendon. The patient learned how to use the newly transferred muscle for the mouth corner movements in 3 months. The problem associated with the presented case is rare, which included facial paralysis followed by blepharoptosis. This is a paradoxical situation. In other words, first, there is a possiblity of having blepharoptosis in a patient with facial paralysis that is already operated on. Second, it might be an intricate problem and I would like to discuss it. Last but not least, it is an example of paradox existing in medicine

Surgery for lipomas should not be estimated as simple as their name implies

This study presents 65 cases with soft tissue tumors. Their histopathological examinations revealed lipomas. Clinically the tumor was located superficially in 26 cases. In 33 patients, the tumor was located deeper. In other words, its was located in either the submuscular or subfascial plane. Lipomatosis was diagnosed in seven cases and lipodystrophic syndrome in five cases. One case with right maxillary enlargement was diagnosed as intraosseous lipoma following its partial resection. The lipomas in lipomatosis cases and lipodystrophic cases were superficially located, yet they were not considered as simple and encapsulated lipomas becasue their resections were not as simple as those of the latter. The emphasis was on the knowledge of the existence of submuscular and subfascial lipomas so that no surgical time was wasted on the superficial adipose tissue to look for the mass. Although it was not difficult to resect the lipomas in superficially located cases, it is believed that liposuction is not a proper treatment for the lipomas seen in the syndromic lipomatosis cases

Upper lip reconstructions in acquired defects excluding melanocytic nevi and vascular tumors

As one of the face's prominent features, the lips help to eat, drink, suck, speak, and kiss, and their functions show certain emotional expressions while communicating with people. Although the lips are without bone and very flexible, they have very close relationships with the upper jaw. Furthermore, the two lips together make the oral sphincter, and none of them has superiority over the other on behalf of the sphincteric functions. A total of 36 cases of upper lip reconstruction were reviewed retrospectively. Melanocytic nevi and tumors in the vascular origin were excluded from the study. All cases were performed sequentially over 25 years by the author. Indications, techniques, postoperative care, complications, and patient characteristics were taken into consideration for each case. Most of the defects resulted from malignant tumor excisions. The procedures used for the upper lip reconstruction included direct closure [n: 5], cheek bilobed flap [n: 4], perialar crescentic advancement flaps [n: 8], full-thickness skin grafting [n: 1], Estlander flap [n: 1], V-Y advancement flaps [n: 3], superiorly based nasolabial peninsular flap [n: 3], perforator-based island flap [n: 6], bilateral depressor anguli oris flaps [n: 1], and musculocutaneous flap combined with local skin flaps [n: 3]. No hematomas, infections, or flap necrosis were reported. One patient died of myocardial infarction during early postoperative days. Most of the defects located on the upper lip can be treated with certain type of perforator-based flaps or perialar crescentic advancement flaps. Since most of the tumors are small or medium sized, an adequate knowledge about these two flaps must be acquired

Any two-lobed flap is not a bilobed flap: a revisited study for the bilobed flap technique

Eighty-two patients aged 1-91 years, who were operated on between 1989 and 2013, were included in this study. Bilobed flaps were used to repair 84 defects in 82 patients. Three flaps were elevated in a fasciocutaneous fashion, and 10 flaps were axial based on well-known vessels. Three flaps consisted of platysma, while the others were random based on unknown vessels. No donor site morbidity was reported, and a single partial necrosis in nasal alar reconstruction was observed. As a late complication, mild trapdoor deformities were found in two patients with upper cheek reconstruction. In three cases, venous stases were were observed in the distal part of the flaps during the early postoperative period. Bilobed flaps were frequently used in nose and infraorbital region. A flap may consist of many shapes and lobes. The reasons for having more than one lobe are as follows: 1] the defect having features that cannot be closed with only one lobe and 2] one lobe is enough to close the defect, but to transfer the lobe to the defect might be associated with a visible morbidity and to facilitate the closure we may need a second lobe. Flaps used for the second situation are termed as bilobed flaps, while the ones used for the first situation are termed as two-lobed flaps

Bilateral knee coverage tissue reconstruction with perforator fasciocutaenous flap in a child

A 5-year-old male patient came to our hospital with injuries on both knees. He got his knees injured when he was clinging to the back of a moving van and his knees were rubbing against the ground. The wounds were sutured primarily in an emergency room. When separation started on both the sutured areas, the parents decided to come to us. After a couple of days of wound care and debridement, we operated the patient on both knees following the same procedure with 1-week interval. The bilateral perforator fasciocutaneous island flaps were elevated using descending genicular artery, and then the flaps were rotated by a 90° angle on its pedicle area. The donor area was repaired primarily and closed up partially by a split thickness skin graft. Our postoperative observation showed that the reconstruction allowed the patient to sit up and sit down comfortably

depressor anguli oris flaps neither with the mental nerve nor the marginal mandibular nerve

A series of 25 cases of lower lip reconstruction with flaps including depressor anguli oris muscle were presented. Depending on the general conditions of each patient, operations were performed under local or general anesthesia. In 4 of the patients, by elevating the flap bilaterally a complete lower lip reconstructions were performed. In three cases, since the defects existed without mucosal involvement, the flaps were elevated only as musculocutaneous flaps. The other cases were repaired by a flap including three layers of skin-muscle and mucosa. In some cases, full thickness skin grafting were necessary, as the mucosa with the flap was not enough for lining. Although not seen in all cases, some fatty appearance on the flap peninsula was observed following the reconstruction. No attempts were made to preserve the so-called flap and mental nerve relationships, except for the first three cases among this series. No patient suffered from any sensorial loss on the newly reconstructed lower lips. Taking into consideration the oral sphincteric functions, although the new oral sphincter was not competent as much as a healthy one, no patient showed incompetence. On the last 5 patients, the flap peninsula was elevated by direct cutting without caring the so-called motor nerve of the flap, too. In an earlier short article of us, it was argued that the depressor anguli oris flap s sensorial innervation did not come from mental nerve but buccal nerve. Now, I would like to add one more discussion about the flap anatomy and this is to say that the flap can be elevated without any attempts to protect neither mental nor marginal mandibular nerve since it may have some cross innervations. This conclusion may make us think that the depressor anguli oris flap is an easy flap to elevate with very little morbidity and can be useful to reconstruct the lower lip defects, except those that are located centrally

Anomalous Origin of Left Internal Thoracic Artery from the Second Intercostal Artery / Origen Anómalo de la Arteria Torácica Interna Izquierda desde la Segunda Arteria Intercostal

Left internal thoracic artery (LITA) has increased importance and common use in coronary bypass grafting because of long-term better patency rate and improvement in both the duration and quality of survival of patients. LITA is a branch of the first part of the subclavian artery. We report a case in which the LITA originated from the second left intercostal artery. A 71-year-old man with a history of angina pectoris for 1 month was admitted to the hospital because of progressive increase in anginal symptoms. During the operation, it was noted that the LITA originated from the second intercostal artery. LITA used as a free graft. LITA was anastomosed to the left anterior descending coronary artery. He was free of symptoms 4 weeks after operation. To our knowledge, this is the first reported case of the LITA originating from the second intercostal artery.

La arteria torácica interna izquierda (ATII) ha aumentado en importancia en su uso como injerto de bypass coronario, debido a su mayor tasa de permeabilidad a largo plazo, y mejora tanto en la duración y la calidad de la supervivencia de los pacientes. La ATII es una rama de la primera parte de la arteria subclavia. Se presenta un caso, en el cual la ATII se originaba desde la segunda arteria intercostal izquierda. Un hombre de 71 años de edad, con antecedentes de angina de pecho durante 1 mes, fue ingresado en el hospital debido al aumento progresivo de los síntomas de angina. Durante la operación, se observó que la ATII se originaba a partir de la segunda arteria intercostal. La ATII fue utilizada como injerto libre, anastomosada a la arteria coronaria izquierda descendente anterior. El paciente se mostró libre de síntomas 4 semanas después de la operación. Este es el primer caso clínico reportado de la ATII originada desde la segunda arteria intercostal.

unaddressed problem of light overexposure due to supraorbital rim fractures and its reconstruction with bone grafting and forehead flap

Three cases of supraorbital rim bone defect causing light overexposure to the affected eye were presented. The bony defect was replaced with iliac bone graft, and to cover it a midline forehead flap was transferred. The flap donor site was closed primarily in two cases and a full thickness skin graft was applied in the third case. For all the presented cases, the main complaint about light overexposure disappeared soon after surgery. I would like to conclude that supraorbital rim is one of the important structures of the craniofacial skeleton. Its defects should be considered for reconstruction no matter how small it seems; since it may be associated with a very disappointing complaint of light overexposure to the affected eye-which to my knowledge have not appeared in the literature so far

most challenging reconstructive procedure for God: fingertip reconstruction

We presented 59 fingertip injury cases that we treated and followed up. Among the 59 patients, 50 were male and 9 were female. The methods we chose for reconstruction were as follows: repairing by a skin graft [n:3], a V-Y advancement flap [n:17], a cross-finger flap [n:19], a thenar flap [n:5], an abdominal interpolation flap [n:8] and infraclavicular flap [n:2]. We performed 35 operations under local anesthesia and 24 under general anesthesia. The waiting time for the second s‚ance of the interpolation flaps was not longer than 12 days for all cases, and we performed the shortest flap separating operation at the end of the seventh day. Since their fingers healed, the patients had no complaints about the donor area. In this study, we did not evaluate the two-point discrimination. Flap-thinning operations were required later, for the abdominal interpolation performed cases. None of the patients had hypersensitivity against touching or cold. From this study it is concluded that regardless of the preferred fingertip repairing method, the evaluation of the finger profile view should not be neglected. It is important to obtain a profile view of repaired fingers similar to that of healthy fingers, and we believe that the pulp softness should be maintained. Although there is a continuous tendency to describe technically complicated and detailed reconstruction methods in literature, we feel the need to emphasize that the classical methods have not lost the value if they are carried out properly

Cytokine measurement in lymphocyte culture supernatant of inactive lepromatous leprosy patients.

The aim of the present study was to determine the effects of stimulation of sonicated Mycobacterium leprae (MLS) extract and phorbol myristate acetate (PMA) on the pattern of cytokine production in peripheral blood mononuclear cells (PBMC) and to find out whether there is any difference between stimulation of MLS extract and PMA. Blood samples were collected and PBMC isolated from 43 inactive lepromatous leprosy patients. After culture for 24 hours, lymphocytes were stimulated with MLS extract and PMA. In the culture supernatant, IL-2, 4, 6, 8, TNF-alpha and TGF-beta levels were measured by using ELISA. M. leprae stimulated group IL-6, IL-8, TNF-alpha, TGF-beta levels were found significantly higher than PMA stimulated group (P < 0.05). However, there was no difference between the two groups for IL-4. Only IL-2 levels were higher in PMA stimulated group than M. leprae stimulated group. Sonicated M. leprae extract have a strong effect on cytokine levels in vitro. Our results suggest that antigens with varying specificities favour the production of distinct cytokine patterns following in vitro restimulation.