Youngest hand injury during cesarean delivery: A case report.

An emergency cesarean surgery resulted in extensor tendon lacerations in a 27-week-old preterm fetus. This injury is unique because fetal hand lacerations rarely occur, and to the best of our knowledge, this is the youngest case of hand injury during cesarean delivery reported in the literature. This case report sets the framework for a more in-depth investigation of the incidence and treatment options for fetal lacerations, with an emphasis on the less common but clinically important hand lacerations that can occur during cesarean section. LEVEL OF EVIDENCE: Therapeutic IV.

Evaluation of the 2023 Kahramanmaras earthquake from the perspective of Plastic Surgery Department: A single-center experience.

OBJECTIVES: The aim of this study was to evaluate the treatment management and demographic data of earthquake victims admitted to Plastic Surgery Department of our center after the 2023 Kahramanmaras earthquake. PATIENTS AND METHODS: Between February 6th, 2023 and February 15th, 2023, a total of 120 patients (65 males, 55 females; mean age: 36.3±17.3 years; range, 85 to 88 years) who were consulted to the Plastic Surgery Department of our center were included. Demographic data of the patients, time to admission to the emergency room, removal time under the rubble, type of injury, emergency operation requirement, fasciotomy requirement, hyperbaric oxygen therapy administration, and length of stay in the intensive care unit were evaluated. After the first intervention, patients with compartment syndrome underwent emergency fasciotomy immediately. Perioperative laboratory values of the patients were followed closely to prevent the development of crush syndrome. RESULTS: Due to stay under the rubble, upper extremity soft tissue injury was seen in 46.2% of the patients. The pelvic and abdominal region were the least affected soft tissues in 1.7% patients. Fasciotomy was performed in 75 patients who stayed under the rubble. Hyperbaric oxygen therapy was applied to 21 of 75 patients who underwent fasciotomy. Amputation was performed in four patients, three of which were in the upper extremity and one in the lower extremity, during follow-up after fasciotomy. A total of 10.83% of the patients were treated conservatively and 11.67% of them were reconstructed with free flaps. Totally 7.5% of the patients who stayed under the rubble were hospitalized in our clinic for maxillofacial injuries. A total of 66.6% of these patients were treated surgically, while 33.3% of them were further treated conservatively. CONCLUSION: Proper triage, proper fasciotomy, and appropriate surgical interventions reduce the amputation rate, yielding clinically satisfactory results.

Outcomes of Wide-Awake Flexor Tendon Repairs in 58 Fingers and 9 Thumbs.

PURPOSE: The purpose of this study was to present the outcomes of wide-awake flexor tendon repairs in zones 1 and 2 in a major hand trauma referral center. METHODS: Zone 1 and zone 2 wide-awake flexor tendon repairs performed between August 2018 and March 2020 were analyzed retrospectively. Outcomes were assessed by the original Strickland-Glogovac criteria for fingers and Buck-Gramcko scoring system for thumbs. Further descriptive analysis of the groups according to potential negative factors, such as injury mechanism, concomitant neurovascular injury, and the extent of injury in zone 2, were performed. RESULTS: A total of 94 tendons were repaired in 67 digits (58 fingers, 9 thumbs) of the 61 patients included in the study. Satisfactory results were achieved in 89.6% of the fingers and 77.8% of the thumbs. Intraoperative gapping was corrected after active digital extension-flexion test in 1 patient. Rupture was seen in 1 patient for a rate of 1.5%. The tenolysis indication rate was 5.1% for fingers and 11.1% for thumbs. CONCLUSIONS: In our series, functional outcome scores, tenolysis, and rupture rates remained similar with findings in the literature. The outcome of a flexor tendon repair is influenced by many factors that cannot be controlled intraoperatively. To assess the effect of performing the repair in a wide-awake setting on the outcome, clinical trials with large patient groups are needed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The effect of local anaesthetic on delayed bleeding in a epigastric flap model of rats.

OBJECTIVE: Local anaesthetics are often used in plastic surgery practice. Through their mechanism of action, local anaesthetics produce a sympathetic blockage with a subsequent vasodilatation and a resulting local increase of perfusion. The effect of vasodilation of the local anaesthetics causes bleeding locally resulting in haematoma, bruising and/or pain. We present an experimental study of the effects of local anaesthetics on delayed bleeding. METHOD: In this animal study, 36 adult male Wistar rats were divided into four groups of nine animals: lidocaine; lidocaine and epinephrine; bupivacaine; and control. An epigastric flap model was harvested. Local anaesthetics that are frequently used in daily practice were administered in equal amounts to the harvested flap. RESULTS: After 24 hours, the rats were euthanised to collect and measure all coagula under the epigastric flap. No statistically significant differences in relation to the amount of coagulum were found between the groups. CONCLUSION: Our results suggest that proper haemostasis is achieved, there is no difference on the effect of delayed bleeding between the local anaesthetics which are often used.

New Technique for the Proximal Leg Reconstruction: Medial Sural Artery-Based Cross-leg Flap.

Reconstruction of the lower extremity, especially the proximal lower leg, is known to be a challenge for reconstructive surgeons. When there is extensive vascular damage, the use of local flaps and microsurgical methods will be limited, so there are few reconstructive options available. We want to define the use of medial sural artery-based cross-leg flap for the reconstruction of the proximal lower leg. A 51-year-old male had a soft tissue defect on the proximal leg region because of a gun-shot injury. We observed that there was no chance of a local flap as a result of CT angiography. We considered free flap to be risky because of extensive vascular damage and medial sural artery-based cross-leg flap was planned. 12*20-cm-sized medial sural artery-based cross-leg flap was elevated from the contralateral leg and adapted to the defect without tension. Medial sural artery-based flap is mostly used as a vascular island for the reconstruction of knee defects. However, its use as a cross-leg flap has not been found in the literature. We believe that it is a safe option to consider in challenging cases such as after flap failure or patients not suitable for a free flap.

Heel Reconstruction With Bipedicled Flap: A Salvage Procedure.

Reconstruction of the heel region poses great challenge to plastic surgeons not only due to calcaneal bone lying just deep to the subdermal fat pad but also due to easily exposed Achilles tendon. In order to achieve permanent closure of the heel defect, exposed bone or tendon-or both-should be covered with durable, preferably sensate, well-vascularized, thin skin flaps. Even though fasciocutaneous free flaps remain the gold standard in the reconstruction of heel defects with exposed bone or tendon, a significant number of these patients are older individuals with multiple comorbidities such as diabetes mellitus, hypertension, atherosclerosis, and peripheral vascular disease. In this study, with a clinic series consisting of 6 patients (1 female, 5 males), we present a new technique of reconstruction with a bipedicled flap as a safe, reliable, and efficient reconstructive modality in the treatment of heel defects in cases where free flaps and other more sophisticated reconstructive options are either not feasible or have failed. Achieving complete reconstruction of defects in all 6 patients, this technique proves to be successful as a salvage procedure in reconstruction of heel defects.

Factors predicting reoperation after hand flexor tendon repair.

BACKGROUND: This single-center, retrospective study aims to analyze the sociodemographic, injury characteristics, and the total number of lost working days of patients undergoing hand flexor tendon repair and to identify factors predicting reoperation. METHODS: Hand flexor tendon repairs conducted using a four-strand modified Kessler core suture with early rehabilitation from January 2013 to December 2016 were included in this study. The variables evaluated in this study were patient sociodemographic and injury characteristics, number of lost working days, and reoperations because of rupture and/or adhesion formation. Injury severity was determined using Modified Hand Injury Severity Scoring (MHISS). Binary logistic regression analysis was conducted to identify the predictors of reoperation. RESULTS: A total of 194 patients were included in this study, who had experienced 329 tendon injuries. Participants were young (mean age, 31.8), mostly male (79.4%), and mostly blue-collar workers (50.0%). Most patients had a zone 2 injury affecting a single digit of the dominant hand. The mean MHISS value was 46.6, and the mean time to return to work was 114.0 days. A total of 37 (19.1%) patients required reoperation because of rupture and/or adhesion formation. Smoking, zone 2 injury, and high MHISS value were negative predictors of reoperation. CONCLUSION: To minimize the need for reoperation, surgeons and rehabilitation teams should take special care of patients with zone 2 injuries, high MHISS values, and smoking history.

Antithrombotic effect of epigallocatechin gallate on the patency of arterial microvascular anastomoses.

BACKGROUND: Microvascular anastomosis patency is adversely affected by local and systemic factors. Impaired intimal recovery and endothelial mechanisms promoting thrombus formation at the anastomotic site are common etiological factors of reduced anastomosis patency. Epigallocatechin gallate (EGCG) is a catechin derivative belonging to the flavonoid subgroup and is present in green tea (Camellia sinensis). This study investigated the effects of EGCG on the structure of vessel tips used in microvascular anastomoses and evaluated its effects on thrombus formation at an anastomotic site. METHODS: Thirty-six adult male Wistar albino rats were used in the study. The right femoral artery was cut and reanastomosed. The rats were divided into two groups (18 per group) and were systemically administered either EGCG or saline. Each group were then subdivided into three groups, each with six rats. Axial histological sections were taken from segments 1 cm proximal and 1 cm distal to the microvascular anastomosis site on days 5, 10, and 14. RESULTS: Thrombus formation was significantly different between the EGCG and control groups on day 5 (P=0.015) but not on days 10 or 14. The mean luminal diameter was significantly greater in the EGCG group on days 5 (P=0.002), 10 (P=0.026), and 14 (P=0.002). Intimal thickening was significantly higher on days 5 (P=0.041) and 10 (P=0.02). CONCLUSIONS: EGCG showed vasodilatory effects and led to reduced early thrombus formation after microvascular repair. Similar studies on venous anastomoses and random or axial pedunculated skin flaps would also contribute valuable findings relevant to this topic.

Delayed bipedicled flap: An alternative and new method for reconstruction of distal leg defect after gunshot trauma: A case report and review of the literature.

Shotgun injury is a trauma that leads to soft tissue defects, in which important structures such as the tendon and bone are exposed with fractures in the distal lower extremity. Because this region has insufficient soft tissue support, local flap options are highly limited. Although the most suitable options are free or perforator flaps for contemporarily reconstructing that region; owing to such highenergy traumas, the available local flaps are becoming more suitable. Besides having various advantages, bipedicled flaps are commonly used for reconstructing small- and medium-sized lower extremity defects. This study aimed to discuss the use of a delayed bipedicled flap, which has not been previously described in the literature.

Effects of Remote Ischemic Conditioning Methods on Ischemia-Reperfusion Injury in Muscle Flaps: An Experimental Study in Rats.

BACKGROUND: The aim of this study was to investigate the effects of remote ischemic conditioning on ischemia-reperfusion injury in rat muscle flaps histopathologically and biochemically. METHODS: Thirty albino rats were divided into 5 groups. No procedure was performed in the rats in group 1, and only blood samples were taken. A gracilis muscle flap was elevated in all the other groups. Microclamps were applied to the vascular pedicle for 4 hours in order to achieve tissue ischemia. In group 2, no additional procedure was performed. In groups 3, 4, and 5, the right hind limb was used and 3 cycles of ischemia-reperfusion for 5 minutes each (total, 30 minutes) was applied with a latex tourniquet (remote ischemic conditioning). In group 3, this procedure was performed before flap elevation (remote ischemic preconditoning). In group 4, the procedure was performed 4 hours after flap ischemia (remote ischemic postconditioning). In group 5, the procedure was performed after the flap was elevated, during the muscle flap ischemia episode (remote ischemic perconditioning). RESULTS: The histopathological damage score in all remote conditioning ischemia groups was lower than in the ischemic-reperfusion group. The lowest histopathological damage score was observed in group 5 (remote ischemic perconditioning). CONCLUSIONS: The nitric oxide levels were higher in the blood samples obtained from the remote ischemic perconditioning group. This study showed the effectiveness of remote ischemic conditioning procedures and compared their usefulness for preventing ischemia-reperfusion injury in muscle flaps.

Necrotizing fasciitis due to Streptococcus mitis caused by accidental human bite.

Human bite wounds are more prone to infection than animal bites, which may cause necrotizing soft tissue infections such as myositis, fasciitis. Both aerobic and anaerobic microorganisms may be responsible, including Streptococcus spp., Staphylococcus aureus, Peptostreptococcus spp. Necrotizing fasciitis is characterized by serious tissue destruction and systemic toxicity with high morbidity and mortality. We report a patient with Streptococcus mitis associated necrotizing fasciitis on the upper extremity resulting from an accidental human bite, which caused nearly fatal infection. Prophylactic antibiotic treatment should be given after a human bite to prevent infection. If the infection signs and symptoms develop, rapid diagnosis, appropriate antibiotic and surgical therapy should be administered immediately. Streptococcus mitis is a viridans streptococcus, usually known as a relatively benign oral streptococcus. To our knowledge, this is the first necrotizing fasciitis case due to Streptococcus mitis after human bite.

Hypothenar island flap: A safe and excellent choice for little finger defects.

Soft-tissue defects of the little finger are challenging especially when bone, tendon or vascular pedicle is exposed because of trauma. The hypothenar island flap is easy to harvest and has a good colour and texture match to the little finger pulp. We present nine clinical cases of soft tissue defects of the little finger covered using the reversed hypothenar fasciocutaneous island flap. This article intends to highlight the ease of elevation and good clinical results of the hypothenar flap which is rarely used.

Perforating arteries of the anteromedial aspect of the thigh: an anatomical study regarding anteromedial thigh flap.

PURPOSE: Because the skin of anteromedial thigh region usually is thinner, pliable, hairless it can be preferred based on the requirements of the recipient site. In this way more information is necessary about the perforators of anteromedial thigh region. The aim of this cadaveric study was described to provide useful knowledge about localizations and number of anteromedial thigh perforators. METHODS: Study was carried out on 16 lower extremities of 9 cadavers. The area in anteromedial aspect of the thigh searched for perforators was defined between the anterolateral border of sartorius and the posterior border of gracilis. The diameters of the dissected perforators were measured and the locations were documented. RESULTS: A total of 204 perforators were dissected in 16 lower extremities. The majority of musculocutaneous perforators were from gracilis (24 of 37) and there were at most 3 musculocutaneous perforators arising from gracilis muscle. 167 septocutaneous perforators were identified. Origin of all perforators was determined as 52 from deep femoral artery, 25 from proximal part of femoral artery and 127 from distal part of femoral artery and their branches. Perforators with the largest diameter were the ones arising from the intermuscular septa between the adductor (longus and magnus) and sartorius muscles. The mean diameter of the perforators was 0.75 ± 0.11 mm and ranged between 0.61 and 0.96 mm. CONCLUSIONS: The septocutaneous perforators of the anteromedial aspect of the thigh are as much important as the musculocutaneous perforators and all they are with adequate to perform anteromedial thigh flap. This study provides numerical overview, useful perception about the localization of the perforators of the anteromedial aspect of the thigh and detailed anatomical basis for anteromedial thigh flap to be an important alternative.

Is it really necessary to make wide excisions for basal cell carcinoma treatment?

Basal cell carcinoma (BCC) is the common malignancy at the skin arising from the cells of the basal layer of the epithelium or from the external root sheath of the hair follicle. It usually occurs at sites with the greatest concentration of pilosebaceous follicles, and it is directly related to sun exposure. Metastasis is rare, but it recurs if it is inadequately treated. For preventive recurrence, BCC is often excised with wide skin margins. It leads to sacrifice of healthy tissue and causes morbidity problems. In our study, we make a treatment plan of excising the primary BCC with its natural tumor margin. Incomplete excision rates were compared between the patient group in which the excisions were performed according to the previously mentioned literature knowledge and the patient group in which excisions were made along the visible outer margins of erythema or induration area surrounding the tumor. In conclusion, there was no statistically significant difference between these 2 groups. This treatment modality is suitable for the excision of BCC, and it eliminates the need for the sacrifice of healthy tissue. This technique also offers the successful functional and aesthetic outcome.Therefore, unnecessary tissue sacrifice can be prevented with this method of treatment. We think our method is the new horizon to ongoing debate of safe excision concept of BCC.

Innervation of three weight-bearing areas of the foot: an anatomic study and clinical implications.

The aim of this cadaver study is to improve our knowledge on the anatomy of the sensory fibres of the three weight-bearing areas of the plantar region. Previous studies mainly focused on the innervation of the heel but the innervation of the other two weight-bearing areas over the most medial and lateral metatarses have been neglected and are not well known. The study was carried out on 10 feet of five male cadavers. The tibial nerve was dissected down to the fat pads over the heel and the first and fifth metatarsal heads under the microscope. The distances of the branching point of the tibial nerve and origins of the medial and inferior calcaneal nerves to a line drawn from the centre of the medial malleolus to the centre of the calcaneous were all measured. The tibial nerve was divided into two branches called the lateral and medial plantar nerves 23.45 mm proximal to the predefined axis. The medial plantar nerve passed underneath the abductor hallucis muscle and gave two sensory branches to the fat pad over the first metatarsal head. The lateral plantar nerve coursed beneath the abductor hallucis and flexor digitorum brevis muscles and supplied innervation of the fat pad over the fifth metatarsal head. The sensory innervation of the heel was provided by medial calcaneal and inferior calcaneal nerves. The medial calcaneal nerve originated from the tibial nerve 41.89 mm proximal to the axis. It divided into two or three branches innervating the fat pad over the heel. The inferior calcaneal nerve originated from the lateral plantar nerve (70%) or the medial calcaneal nerve (30%) 10.66 mm proximal to the axis. This study describes the sensory fibres to the heel and the previously neglected weight-bearing areas over the first and fifth metatarses. Reconstruction of defects in these areas is very difficult so every attempt should be made to protect the sensory fibres during any surgical procedure.