Chronic pelvic abscedation after completion proctectomy in a rectal stump insufficiency; treatment with gracilis muscle flap following vacuum assisted closure therapy.

Presacral abscess formation due to rectal stump insufficiency following Hartmann procedure is very rare complication. If the abscess cavity is large, it might delay the reversal of the stoma and will probably result in a devastating future functioning of the neorectum. Moreover, very invasive treatments will be required in order to prevent severe septic complications. We present the case of a 58-year-old man with a past history of Hartmann procedure for a low rectal carcinoma who presented with rectal stump insufficiency and a large presacral abscess. Following extensive debridement and rectal stump resection, a vacuum-assisted closure (VAC) system was applied to the large abscess cavity to facilitate gracilis muscle flap reconstruction and to optimize wound healing. The satisfactory results showed in the present report led us to favor a combination of VAC therapy and a gracilis muscle flap in intrapelvic and perineal reconstruction in the case of large defects associated with high risks of septic complications.

Mammae erraticae: a case report and reappraisal of the related theories.

UNLABELLED: Extra nipples and breast tissue outside the orthotopic location of the mammary glands are called polythelia and polymastia, respectively. Although the theory of mammary ridge remnants can explain extra breast tissue along the milk line, other locations such as the dorsum of the body still need further discussion. This report describes a 28-year-old Caucasian woman with a perfectly formed breast together with a meningocele in the lumbar region. Kyphoscoliosis and growth retardation were accompanying pathologies. As far as the authors can discern, this is the first case in the literature showing a well-formed breast and dysraphism occurring together. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

An alternative approach for involutional entropion: a preliminary study.

Involutional entropion is an inward rotation of the eyelid margin because of increased horizontal lid laxity, an overriding preseptal orbicularis, atrophied lid retractors, and involutional enophthalmos. There are a myriad of surgical approaches to treat involutional entropion, but the medical co-morbidities that are common in this patient population often make a less-invasive method more appropriate. In this study, a novel and less-traumatic method was tested. Tissue shrinkage effect of the CO(2) laser was used to create cicatricial changes to treat involutional entropion in five patients. Resurfacing was accomplished with the Ultra Pulse CO(2) (carbon dioxide) laser (model UP 5005, Coherent Medical Group, Santa Clara, CA) by the help of computerized pattern generator (CPG) scanning device. The first pass was performed to the entire lower lid and periorbital area, sparing the subciliary region, using 200 mJ of energy. The second pass used the same energy level, but this time resurfacing was extended as close as the lash line. All four of the five patients available for follow-up clinical evaluation (interval between 5 and 21 months) had surgical success with no recurrence of entropion, or symptoms such as itching or irritation. One of the patients who never came back for routine was lost to follow-up. The ectropion was never seen in the long-term follow-up. This method is a suitable alternative for elderly patients with comorbid conditions that prevent them from having invasive surgical procedures.

The effect of the Botulinum toxin-A on craniofacial development: an experimental study.

In this study, we developed a novel experimental model to evaluate muscular action on bone formation and remodeling by the help of Botulinum toxin-A (BTX). Forty-nine 15-day-old male Wistar rats were put into 4 groups randomly. Group 1 was the control group. BTX 0.4 IU (0.05 mL) was injected into the right masseter muscle in group 2 and into right temporalis muscle in group 3. The same volume of sterile saline was given into the both above-mentioned muscles in group 4. At the end of the fourth month, all animals were killed. Histology and weight of the masseter and temporalis muscles were studied. Thirty different osteometric measurements were also taken from skulls. Significant atrophy in BTX injected muscles was observed in groups 2 and 3. In group 4 (saline injection), only few osteometric measurements were significantly reduced, indicating the effect of the injection itself. Both groups 2 and 3 have apparent decrease in nasal bone, premaxilla, maxilla, and zygomatic dimensions on the injected side. When masseter group was compared with control and saline groups, no significant difference was found in skull base dimensions and mandibular length. In contrast, temporal group has also shown significant decrease in skull base dimensions. Our conclusions are as follows: (1) With this model, it is possible to study muscular action on bone formation and modeling without any surgical intervention, that is, by avoiding surgical artifacts, such as scar and contracture; (2) denervation of the skeletal muscles with BTX during the growing phase does effect bone development in a negative way; (3) pediatric use of the BTX deserves reevaluation under the light of these findings.

An ameliorated skin flap model in rats for experimental research.

There is a disagreement in the experimental design of random skin flaps owing to their vascular inconsistency. The definition of a reliable axial-pattern skin flap model is needed. The purpose of this study was to describe a new skin flap model to deal with entire drawbacks of existing random and axial pattern skin flap designs. This was accomplished by creating paired skin flaps including both skin and vascular pedicle on the dorsum of the same rat. This design was suitably termed as rando-axial flap. The present study offers a simple and reliable skin flap model with following advantages: (1) it has a predictable necrosis area, (2) it reveals a larger survival area (75 +/- 5%) when compared to other flaps in this study (Mann-Whitney U-test, p<0.001), (3) the vascular pedicle is consistent, (4) control and study flaps are placed on the same animal (5) it can be converted to a random, an axial or a free flap.

[The effect of combined use of vitamin C, vitamin E, and ibuprofen on flap viability: an experimental study]. / C vitamini, E vitamini ve ibuprofenin birlikte kullanilmasinin flep yasamina etkisi: Deneysel çalisma.

OBJECTIVES: Many studies have been carried out to investigate the individual effects of vitamin C, vitamin E, and ibuprofen on flap viability, with favorable results. This study aimed to determine the effect of combined use of these agents on flap viability. DESIGN AND METHODS: Sixty Wistar rats weighing 250-300 grams were divided into six groups, equal in number, to receive saline solution (group 1, control), vitamin C (group 2), vitamin E (group 3), vitamin C and E (group 4), ibuprofen (group 5), and vitamin C, vitamin E, and ibuprofen (group 6). Following ketamine anesthesia, a caudally based reverse McFarlane flap on the back of the rats, 3x10 cm in size, was elevated and sutured back. The agents were administered intraperitoneally once daily for seven days, after which viable flap areas were estimated. RESULTS: The percentages of the viable area of the flaps in groups 1, 2, 3, 4, 5, and 6 were 58.0%, 68.1%, 61.4%, 73.4%, 69.1%, and 80.5%, respectively. The use of vitamin C, vitamin E, and ibuprofen in combination resulted in a significantly greater flap viability compared to individual uses. CONCLUSION: Administering vitamin E and vitamin C together has a greater effect on flap viability than used alone; however, the benefit is the greatest with the addition of ibuprofen.

No-vertical-scar technique versus inverted T-scar technique in reduction mammoplasty: a two-center comparative study.

Currently, a reverse T-shaped scar remains in the infraareolar area after most of the frequently used techniques for reduction mammoplasty. A two-center study was performed for an understanding of the effects from the amount of scars on the aesthetic satisfaction of patients. Long-term follow-up results for 24 patients who underwent the McKissock (inverted T-scar) technique (group 1) in a university hospital were compared with the results for 29 patients who underwent a "no-vertical-scar technique" (group 2) at another hospital in terms of aesthetic results. With this aim, a questionnaire was designed to assess the patients' degree of aesthetic satisfaction with different aspects. Additionally, the most current photos of each patient were evaluated for aesthetic results by four physicians and four medical students. Areola-fold and nipple-notch distances were measured as an objective evaluation. The significance of the results was tested using dependent or independent sample t tests. Notch-nipple and areola-fold distances both were greater in group 2 than in group 1, both preoperatively and postoperatively (p < 0.001). The personal satisfaction questionnaire showed that the group 2 patients rated scar satisfaction and postoperative activity levels higher (p < 0.001) than the group 1 patients (p < 0.05), but that group 1 rated nipple position higher (p < 0.05). There was no significant difference between the two groups in terms of general aesthetic satisfaction. Physicians who evaluated patient photos ranked the scars of group 2 as significantly superior to those of group 1 (p < 0.01), whereas they did not rate other features as significantly different. However students could not determine any superiority of any feature between the two groups. The no-vertical-scar technique gives the impression of a breast that has not undergone surgery because it leaves no scars in the infraareolar area and invisible scars in other areas. This situation improves the degree of satisfaction for patients in the postoperative period. When the general aesthetic success and the ratio of complications were evaluated, the no-vertical-scar technique was found to be just as successful as the T- scar technique, which is practiced widely.

Hemangioma of the nasal bone: a case report.

Hemangiomas of the bone account for 0.7% of all bone tumors. The craniofacial region is a rare site of involvement, with the mandible, zygoma, and maxilla being the most frequently affected areas. Hemangioma of the nasal bone is very rare. A 60-year-old male patient presented with complaints of difficult breathing through the nasal airway and a slowly growing hard mass at the nasion with a history of 10 years. Computed tomography demonstrated a round mass involving the left nasal bone with submucosal extension. An en bloc excision of the mass and its extension was performed. Histopathological examination showed two neighboring tumors, cavernous hemangioma of the bone and arteriovenous malformation of the nasal mucosa. During a-year follow-up, the patient had no complaints and the functional and cosmetic results were excellent.

The postoperative analgesic effect of tramadol when used as subcutaneous local anesthetic.

Recently, it has been shown that tramadol was an effective local anesthetic in minor surgery. In this study, its efficacy for relieving postoperative pain was evaluated. Forty patients undergoing minor surgery (lipoma excision and scar revision) under local anesthesia were included. The patients were randomly allocated into two groups: In group T (n = 20), 2 mg/kg tramadol, and in group L (n = 20), 1 mg/kg lidocaine were given subcutaneously. In both groups, the injection volume was 5 mL containing 1/200,000 adrenalin. The degree of the erythema, burning sensation, and pain at the injection site were recorded. Incision response, which is a degree of the pain sensation during incision, was recorded and graded with the visual analog scale (VAS) 0-10. After incision, VAS values were recorded at 15-min intervals. When the VAS score of the pain during surgery exceeded 4, an additional 0.5 mg/kg of the study drug was injected and this dosage was added to the total amount. Patients were discharged on the same day. Subjects with VAS > or =4 were advised to take paracetamol as needed. No side effects were recorded in either group except for 1 patient complaining of nausea in group T at the 30th min of operation. After 24 h, patients were called and the time of first analgesic use and total analgesic dose taken during the postoperative period were recorded. During the 24 postoperative hours, 18 of 20 (90%) subjects did not need any type of analgesia in group T, whereas this number was 10 (50%) in group L (P < 0.05). The time span before taking first analgesic medication was longer (4.9 +/- 0.3 h) in group T than that of group L (4.4 +/- 0.7 h) (P < 0.05). We propose that tramadol can be used as an alternative drug to lidocaine for minor surgeries because of its ability to decrease the demand for postoperative analgesia.

Dual synergistic effect: the effect of dexamethasone plus carnitine on skin flap survival.

Dexamethasone has well-known useful effects in dealing with the progression of necrosis. Carnitine is an endogenous cofactor, for having a regulatory action on the energy flow from different oxidative sources. The aim of this study was to determine whether combined local dexamethasone and systemic carnitine administration would result in an additive enhancement of skin flap survival in the rat model. A rectangular (3 cm x 11 cm) dorsal random skin flap was elevated on the rats and then sutured back into its original site with separate sutures. Overall, 40 rats were allocated randomly into 4 groups: Group 1 (control group, n = 10), group 2 (Dexamethasone group, n = 10, 2.5 mg/kg), group 3 (carnitine group, n = 10, 100 mg/kg), group 4 (dexamethasone plus carnitine group, n = 10).The mean flap survival area was 57.50 +/- 5.2% (mean survival area +/- SD) in control group (group 1), 71.5 +/- 4.8% in the dexamethasone group (group 2), 73.0 +/- 5.5% in the carnitine group (group 3), 85.30 +/- 6.1% in the dexamethasone plus carnitine group (group 4). In conclusion, based on the findings of this experimental study, the synergistic effect of carnitine and dexamethasone on skin flap viability is determined.

Effect of cerebrospinal fluid leakage on wound healing in flap surgery: histological evaluation.

The aim of this study was to find out the effect of CSF leakage on wound healing after flap surgery. Sixteen male Wistar rats were used. The superiorly based rectangular dorsal skin flap 3 x 3 cm was elevated at the interscapular region. Through this opening, paraspinal muscle dissection and three-level bilateral laminectomy were done. Finally, a dura defect with a diameter of 3-4 mm was created. In the control group, laminectomy was performed as in the study group but the dura was left intact. Persistent CSF leakage was confirmed using isotope cisternography. At the end of 2-week study period, there was no necrosis, infection, or dehiscence of the flap in either group. On necroscopy, cyst formation over the dura defect was detected in 4 animals of the study group. Another gross finding in this group was intensive vascularization of the undersurface of the flap and wound bed. With HE staining, the tissue sections from the study group revealed new vessel formation with small diameter, increase in the reactional mesenchymal tissue, granulation tissue, degeneration of the striated muscle fibers, dystrophic calcifications, fat necrosis, and coagulation necrosis (ischemic necrosis). In the control group, there was only minimal lymphocytic invasion of the subdermal plane. In this study, we have shown that CSF leakage itself has effects on wound healing in the absence of known causative factors.

Evaluation by scintigraphy of hindlimb ischemia in a rat model.

The subject of ischemia-reperfusion has commonly been studied in rat hindlimb models. Unfortunately, in these experiments, the ischemia procedures lack standardization. For this reason, the authors evaluated the reliability of rat ischemia models described in the literature using scintigraphy. The study comprised six groups. Each consisted of ten male Wistar rats; five of them underwent methoxy-isobutyl-isonitrile (MIBI) scintigraphy, which is specific for muscle, and the others underwent methylene diphosphanate (MDP) scintigraphy, which is specific for bone. In Group 1, only the iliac artery was ligated; in Group 2, the iliac artery and its branches, except for the superficial epigastric artery, were ligated; in Group 3, the iliac artery and vein were ligated; in Group 4, the iliac artery and all branches, including the superficial epigastric artery, were ligated; in Group 5, in addition to ligation of the iliac artery and its branches, the skin was incised circumferentially around the pelvic girdle; in Group 6, a tourniquet was applied to the limb at the pelvic level. After 2-hr warm ischemia, a radioactive tracer was injected intravenously. In the MIBI group, images were taken at the twentieth minute and second hour after injection, and in the MDP group, at the fifth minute and third hour after injection. The radioactivity in both hind limbs of the animal was measured, and the ratio of the control to the ischemic limb was calculated. In the first five groups, there was no necrosis in the ischemic limb at the end of 2 weeks. The measured radioactivity in the ischemic limb was lower than that of the control limb in all groups. The ratio of activity obtained from the control limb to that of the ischemic limb in the tourniquet group was significantly higher, compared to other groups in both MIBI and MDP evaluations (p < 0.005). Significant ischemia was also seen in the skin incision group (Group 5). A low-flow state was observed in the ischemic limb in Groups 1-4 using both scintigraphic modalities. The tourniquet method (Group 6) provided almost complete limb ischemia, compared to other arterial ligation methods, and it is practical to use for complete ischemia when studying the physiology of replantation or free flaps.

The effect of CAPE on lipid peroxidation and nitric oxide levels in the plasma of rats following thermal injury.

Both experimental and clinical studies have shown that oxygen-derived free radicals rise in the plasma after thermal injury and participate in the pathogenesis of tissue damage. Hence, various antioxidant molecules have been used in treatment of burn injury both experimentally and clinically. Caffeic acid phenethyl ester (CAPE), an active component of propolis from honeybee hives, is known to have potent antioxidant property. The purpose of the present study was to investigate the effects of CAPE on oxidative stress in plasma of burned rats. Experiment was designed in three groups of rats with 20% full-thickness burn: (a) sham burn (n = 7); (b) burn only (n = 22); (c) burn + treatment with CAPE (n = 22). Plasma levels of malondialdehyde (MDA), nitric oxide (NO) and the activities of xanthine oxidase (XO), and superoxide dismutase (SOD) were used as both bio-indicators of oxidant status and determinant of antioxidant effect of CAPE. They were assessed by biochemical methods at 1st, 3rd, 7th, and 14th post-burn days. In conclusion, CAPE was shown to possess antioxidant activity by saving SOD activity, preventing XO activity and decreasing the levels of MDA, and NO. Our study showed that CAPE may be beneficial in burn injury.

Relaxation incision and fascia lata grafting in the surgical correction of penile curvature in Peyronie's disease.

The purpose of this study was to evaluate the effects of treatment of curvature in Peyronie's disease with a relaxation incision and fascia lata grafting. Between 2000 and 2002, this technique was used for 12 patients with a 1-year history of plaque and curvature of more than 35 degrees. Penile degloving was performed with a circumferential incision. The tunica defect was closed with fascia lata grafting after a relaxation incision. For all patients, penile curvature was corrected and normal erections were achieved. No complication was observed in 9 to 24 months (mean, 10 months) of follow-up monitoring. The initial results suggested that tunica albuginea incision and fascia lata grafting could represent an alternative for the treatment of curvature in Peyronie's disease. Further studies are warranted.

Morphology of the gluteal region in the female population 5 to 83 years of age.

This study evaluated the development of gluteal region morphology in the female population 5 to 83 years of age. For the study, 132 female subjects were placed into four groups: prepubertal (ages 5 to 8 years; n = 10), pubertal (ages 9 to 14 years; n = 38) postpubertal (ages 15 to 41 years; n = 34), and menopausal-postmenopausal (older than 42 years; n = 29). The age, weight, and height of the subjects were routinely recorded, and body mass index was estimated. In addition, 11 measurements were performed on the gluteal region. The data were analyzed by Pearson and Spearmen correlation analyses using SSPS 11.0 for Windows. In the prepubertal group, the intergluteal sulcus and infragluteal sulci did not actively change. Weight gain was the major factor influencing the shape of the gluteal region, whereas age had no effect. In the puberty group, the gluteal region expanded in all directions. During this period, it was difficult to determine any specific relation between measurements because of significant correlation involving all parameters. However, it should be mentioned that among the four groups, only in pubertal group did age significantly affect the shape of the gluteal region. In other three groups, weight seemed to be a major determinant. In the pospubertal and menopausal-postmenopausal groups, the buttocks sagged with weight gain, contrary to the belief that this happens with aging. This causes movement of the infragluteal sulci in downward and lateral directions as well as lengthening of intergluteal sulcus. Although the gluteal shape is open to the effects of demographic factors such as ethnicity, feeding habits, and lifestyle, according to these findings, it might be advised that in the assessment of the gluteal region morphology, it would be better to consider its dynamic nature. Reshaping its only one part, which can be devastating unless the whole gluteal region and upper limb are addressed.

Midline cleft of the lower lip associated with Robinow syndrome.

Robinow syndrome (also named "fetal face syndrome") includes a series of anomalies including mesomelic brachymelia, bifid terminal phalanges of the hands and feet, abnormalities of vertebrae and ribs, and hypoplastic external genitalia. A midline cleft of the lower lip and mandible is an extremely rare maxillofacial deformity. Seventy cases have so far been described to our knowledge. We report a patient with Robinow syndrome and midline cleft of the lower lip and mandible and describe the reconstruction of these anomalies. We propose that this anomaly should be added to the range of malformations associated with the syndrome.

Atypical presentation of Kaposi's sarcoma in the external ear.

We presented a case of Kaposi's sarcoma that occurred in the external ear of a 36-year-old Caucasian man. He was otherwise healthy without a history of any predisposing factors. He had a nodular lesion in the left ear, of three-month duration. The lesion was excised completely. Histologic and immunohistologic findings were consistent with a diagnosis of Kaposi's sarcoma. Serologic analyses were negative for anti-HIV antibody and anti-cytomegalovirus IgM and IgG and blood count was normal. Differential count of leucocytes and immunoglobulin electrophoresis were normal. During a two-year follow-up, no recurrences, development of new lesions, or HIV seroconversion were detected. To our knowledge, this case is the first to report a solitary lesion of Kaposi's sarcoma occurring in the helix of the ear in a healthy young patient.