Neutrophil gelatinase associated lipocalin as an indicator of acute kidney injury and inflammation in burned children.

INTRODUCTION: Neutrophil gelatinase associated lipocalin (NGAL) is a novel predictor of acute kidney injury (AKI), which increases with inflammation. We aimed to assess whether serum NGAL (SNGAL) and urine NGAL (UNGAL) can predict AKI in burned children. METHODS: Patients were referred within the 12 h of burn to our center. Serum samples for SNGAL, C-reactive protein (CRP), procalcitonin (PCT) and urine for UNGAL, microalbumine (Umalb), creatinine (Ucr) were obtained at both admission and the 5th day after burn. Blood urea nitrogen (BUN) and serum creatinine (Scr) were examined daily. RESULTS: Twenty-two subjects were enrolled and six (27.2%) of them developed AKI within the 48 h of injury. Burn size and abbreviated burn severity index (ABSI) were significantly increased in patients with AKI. CRP, PCT, SNGAL and UNGAL levels at admission and day 5 were significantly higher in patients with AKI than in those without AKI and controls. Scr was not significant between AKI and non-AKI groups at hospital days 1 and 5. A SNGAL level of 315 ng/ml and a UNGAL level of 100 ng/ml were determined as predictive cut-off values of AKI at admission (sensitivity and specificity: 71.4%, 83.3% and 93.3%, 93.7%, respectively). SNGAL and UNGAL were positively correlated with CRP, PCT, ABSI and Umalb/Ucr. CONCLUSION: SNGAL and UNGAL are good early predictors of AKI in children with severe burn. NGAL might reflect the severity of burn insult and also could be used as an indicator of inflammation in burn children.

Upper extremity salvage with a flow-through free flap.

In complex extremity injuries, which include composite tissue lost with devascularization caused by segmental vascular damage, simultaneous coverage of the defects with revascularizations should be required. One-stage reconstruction of both soft tissue coverage and vascular damage can be performed by a flow-through-type free flap. In this series, 5 patients between 13 and 36 years of age with wide composite tissue defects in the cubital region and segmental defects in brachial arteries were operated at our clinic between 1996 and 2003. With the aim of reconstructing the wide tissue defects in the cubital region as well as that of the brachial artery, a radial arterial flow-through flap was applied. The radial artery of the flow-through flap was anastomosed to the proximal ends of the brachial and ulnar arteries in an end-to-end fashion. In 4 of the patients, the radial arterial flow-through flap was prepared from the distal aspect of the wounded forearm and in 1 patient from the contralateral forearm. In the postoperative period, no complications related to the anastomosis were encountered in the flap with all anastomoses found to be patent, and distal circulation was restored. The radial arterial flow-through flap is very useful in the clinical field of major trauma of the cubital region with brachial artery damage with numerous advantages that include the opportunity to work in one single surgical area, shorter dissection times resulting from simple and fixed anatomy, perfect color and tissue adaptation, and the suitability of the vessel caliber and length.

Lighted retractor-assisted transaxillary approach in gynecomastia correction.

Gynecomastia is an excessive development of the male breast. Surgery is the accepted standard method for treatment. In our department, 5 male patients ranging in age from 18 to 24 years who had grade I-IIA-IIB gynecomastia according to Simon's classification were operated on with a lighted retractor-assisted transaxillary approach. Dissection, excision, and hemostasis were performed under direct vision by using the lighted retractor. The glands and adjacent fat were removed en bloc. The axillary scar was barely visible. The patients were satisfied with the results. Gynecomastia correction with a lighted retractor-assisted transaxillary approach is feasible for those who have grade I-IIA-IIB gynecomastia according to Simon's classification and also for those who do not want to have scars on their breasts' esthetic units and have a tendency towards keloid formation. Scars can be kept in the hidden area, with no considerable complication. The lighted retractor facilitates the transaxillary approach and provides appropriate dissection, excision, and hemostasis.

An algorithm for deciding alternative grafting materials used in secondary rhinoplasty.

Severe middle vault deformity with disturbed nasal form and function is one of the most challenging procedures to correct in a secondary rhinoplasty. Reconstructing the deformity with autologous septal cartilage would be the primary choice of most surgeons, if it were always available. However in certain cases the lack of a sufficient quantity of autologous cartilage has forced surgeons to explore other viable options. This paper discusses our experience with the combined use of spreader and dorsal onlay grafts from various materials in the reconstruction of severe middle vault deformity in 110 patients. In follow up, (between 6 and 42 months; mean 21 months) all patients were noted to have improved in both aesthetics and function with no major complications noted. In summary, this study proposes that any engrafting material can be used safely when the proper surgical principals and technique are employed.

Lesch-Nyhan syndrome: reconstruction of a calcaneal defect with a sural flap.

Lesch-Nyhan syndrome is a familial disorder of uric acid metabolism and dysfunction of the central nervous system. We present a patient with the syndrome, who had a defect of the left calcaneal tissue with osteomyelitis caused by repeated self-mutilation. The defect was reconstructed with a sural flap.

Coverage of scalp defects following contact electrical burns to the head: a clinical series.

Fifteen patients with various scalp defects resulting from contact electrical burns to the head, were reconstructed between the periods of January 1989 and October 2004 in our burns unit. The incidence of scalp burns in our patient population was 2.99% for electrical injuries and 0.95% for all burns during the study period. We present here a clinical series of fifteen patients with large, complex scalp defects following contact electrical burns to the head treated successfully by the application of local and free flaps. In this series, four free flaps, one pedicled flap and 10 local flaps were used for the reconstructions with no major postoperative complications seen. The average size of the defect was 89.45 cm2 for cases in whom local flaps were applied, 193 cm2 for free flaps and 143 cm2 for one case treated with distant flap. Four cases required craniectomies because of the delay in reporting to our burns unit. Early surgical attempt to cover the defect with a well-vascularized tissue provides excellent healing, osteogenesis, short hospital staying, low rate of infection and requires no surgical debridement of the bone in the early phase.

Reconstruction of deep cubital fossa defects with exposure of brachial artery due to high tension electrical burns and treatment algorithm.

In this paper, we selected eight patients who had cubital fossa electrical burns with exposure or damage of the brachial artery, during the period 2000 to 2004 and formulated an algorithm to salvage upper limbs. We demonstrated the effectiveness of the algorithm to rescue the extremity from amputation and to restore the functional ability combined with coverage of the defects. After initial management with decompression and debridement of the nonviable tissues surrounding the brachial artery, we used local fasciocutaneous flaps or pedicled latissimus dorsi (LD) muscle/musculocutaneous flaps immediately to cover and also to avoid the perforation of this artery with a mean of 5.5 operations and with an amputation rate of 12.5%. When perforation or necrotic focus was seen on the arterial wall without viable tissue around the brachial artery, circulation was restored with vein grafts. Deep defects in the cubital fossa with exposure of the brachial artery should be covered with well-vascularized tissue as soon as possible after serial debridements. If the necrotic focus is seen on the wall of the artery, it often requires a venous graft with flap coverage. In the presence of viable tissue around the artery, however, fasciocutaneous flaps are useful and they reduce the operation time and duration of hospital stay. We treated deep defects with exposure of the brachial artery in the cubital fossa according to our established algorithm. Adherence to this approach precluded dilemmas in the selection of flap types for the management of bulky tissue defects.

An uncommon complication of secondary augmentation mammoplasty: bilaterally massive engorgement of breasts after pregnancy attributable to postinfection and blockage of mammary ducts.

Augmentation mammoplasty is one of the most frequently performed aesthetic operations. Galactorrhea and galactocele formation after augmentation mammoplasty, while the patient is experiencing the hormonal effects, is rarely seen. The cause remains unknown. However, postoperative fibrosis and blockage of the mammary ducts after augmentation mammoplasty is a probable cause of this formation in some patients. In the reported case, the patient described painful massive engorgement of both breasts during the last month of pregnancy and inability to breast-feed after delivery. In her history, she had undergone breast augmentation via the semicircular periareolar transglandular approach. She had experienced an infection at an early stage of her postoperative period and had needed to have both prostheses removed. A second breast augmentation mammoplasty was performed 1 year after the first operation via the same incision. She was content with the result of her second augmentation mammoplasty, up until her third pregnancy, at which time she reported inability to breast-feed after her delivery. At our examination, it was determined that there was massive painful breast engorgement, hyperemia, and inflammation of both breasts attributable to a bilateral galactocele formation. She refused to take any medication (bromocriptine), but approved antibiotic treatment. The patient responded to the antibiotics, and the prostheses therefore were left in place without further complications.

Mega dose corticosteroid treatment for traumatic superior orbital fissure and orbital apex syndromes.

The superior orbital fissure syndrome and orbital apex syndrome are rare complications of craniomaxillofacial traumas. The neurologic symptoms are generally due to reversible neuropathy caused by edema, contusion, and compression of the nerves. Much has been written but no firm conclusions have been reached on the best mode of treatment. Whereas some authors advocate emergency optic nerve decompression, others recommend mega dose corticosteroids alone. We have treated 11 patients with traumatic superior orbital fissure or orbital apex syndromes with mega dose corticosteroids in the last 10 years. No complications attributable to the very high dose of corticosteroids were observed. The long-term follow-up of the patients showed complete recovery. These satisfactory results have led to our recommendation of the mega dose corticosteroid treatment in the management of these patients.

The spreader-splay graft combination: a treatment approach for the osseocartilaginous vault deformities following rhinoplasty.

Deformities following primary rhinoplasty may be located at different anatomical regions related to the primary operation. Osseocartilaginous vault deformities such as open roof deformity, over-resected bony and cartilaginous dorsum, excessive width of the middle vault, inverted-V deformity and middle vault collapse are the most frequent ones. Stair-step deformity combined with middle vault problems is uncommon. Patients with these deformities not only have poor aesthetic results, but also have moderate or severe respiratory problems due to the severity of the deformity. Spreader grafts, onlay grafts and biomaterials can be used to correct these deformities. We preferred to use the spreader-splay graft combination for severe osseocartilaginous vault deformities. In this paper we present 3 cases. Two cases had severe open roof deformity, middle vault collapse and over resection of the osseocartilaginous hump, along with severe respiratory problems. The Spreader-splay graft combination was used, along with lateral osteotomy and medialization of nasal bones to treat these patients. One patient had a very severe stair-step deformity due to over resection of the hump and excessive infracturing of nasal bones along with severe respiratory problems due to collapse of the middle vault. This deformity was corrected with proper outfracturing along the old osteotomy site and the use of spreader-splay graft combination. All patients had good aesthetic and functional outcome after the surgery. In conclusion, the spreader-splay graft combination provides a good anatomical restoration to obtain a better respiratory function and aesthetic outcome on severe osseocartilaginous vault deformities following rhinoplasty.