The effects of gender-affirming hormone therapy and mastectomy on psychopathology, body image, and quality of life in adults with gender dysphoria who were assigned female at birth.

PURPOSE: Individuals with gender dysphoria (GD) may request hormone therapy and various surgical operations to change their physical characteristics. The present study aimed to investigate the effects of two treatments, mastectomy and gender-affirming hormone therapy (GAHT), on adults with GD who were assigned female at birth (GD AFAB). METHODS: In this cross-sectional study, we gathered data from a total of 269 individuals in three groups: (a) untreated group (n = 121), (b) GAHT group (n = 84) who had been receiving treatment for at least 6 months, and (c) GAHT-MAST group (n = 64) who had been using GAHT for at least 6 months and had undergone mastectomy at least 3 months prior. All participants were asked to complete the Symptom Checklist-90-Revised (SCL-90-R), the Body Uneasiness Test (BUT), and the World Health Organization's Quality of Life Questionnaire- Brief Form, Turkish Version (WHOQOL-BREF-Tr). RESULTS: We found that individuals in the untreated group had higher psychopathological symptoms and body uneasiness scores, and lower quality of life scores compared to both GAHT and GAHT-MAST groups. There was no difference in psychopathology between the GAHT-MAST group and the GAHT group, but body uneasiness scores were lower, and quality of life scores were higher in the GAHT-MAST group. CONCLUSION: Our study suggests that individuals receiving GAHT improved mental health, body satisfaction, and overall quality of life. Combining mastectomy with GAHT may further enhance these benefits.

Expansion of the Subcutaneous Compartment by Umbilicus Resection for Intrathecal Pump Placement: The "Karagoz-Hacivat Technique".

BACKGROUND AND OBJECTIVES: Intrathecal baclofen (ITB) for severe spasticity can encounter complications such as wound dehiscence and ulcers because of elevated intracompartmental pressure within the abdominal subcutaneous and subfascial pocket housing the pump. We propose an innovative technique to manage ITB wound ulcers. METHODS: Resecting the umbilicus create a more spacious and less tension-prone pocket for the ITB pump. RESULTS: Between 2015 and 2023, we implanted ITB pumps in 65 patients. Among them, 5 patients presented with skin ulcer or dehiscence underwent surgery using the novel technique. Postoperative follow-up revealed successful wound healing, with no further wound-related complications. CONCLUSION: The proposed technique provides effective and practical solution to wound and skin complications related to ITB pump. Moreover, it may serve as a viable preemptive strategy during the initial implantation of the ITB pump in selected patients.

Superficial Temporal Artery Posterior Branch Flap for Reconstruction of Composite Oral/Perioral Defects.

PURPOSE: Defects involving total lower and/or upper lip often extend to intraoral and/or perioral areas. Flaps based on superficial temporal artery, either as pedicled or free flaps, can be used for reconstruction of various head and neck defects. In this clinical study, we tried to demonstrate the application of a pedicled flap based on the posterior branch of superficial temporal artery in 3-dimensional reconstruction of these composite oral/perioral defects as a successful alternative in cases where microvascular tissue transfer cannot be performed. PATIENTS AND METHODS: Six male patients with composite perioral/oral defects who underwent reconstruction with a pedicled flap based on the posterior branch of the superficial temporal artery between April 2020 and December 2020 were evaluated retrospectively. Demographic data, topographic data of defects, and the dimensions of the flaps were gathered from patient files. All patients required reconstruction after tumor resection. RESULTS: All flaps survived without any signs of partial or total necrosis. Postoperatively, the patients did not report any oral incompetence or drooling, and they were able to fully close their mouths. CONCLUSIONS: Pedicled flaps based on the posterior branch of superficial temporal artery provide reliable results in composite perioral/oral reconstruction.

Periosteal Turnover Flap for Coverage and Salvage of Exposed Deep Brain Stimulation Device.

Implanted deep brain stimulation (DBS) devices are crucial in the treatment of movement disorders. Hardware extrusion is among the most frequent complications of the implantation process and requires reconstruction with well-vascularized tissues. The authors present a case of periosteal turnover flap for coverage of an exposed DBS device. An 11-year-old female patient with spastic cerebral palsy presented with an exposed DBS device located in the right parietal area. The exposed device was covered by a proximally based periosteal flap. Postoperative evaluations at months 1, 2, 3, and 8 revealed no signs of infection or dehiscence. This brief clinical study shows that reconstruction with periosteal turnover flaps is both an easy and excellent choice for secondary closure of exposed DBS devices.

Morphological, histological and biomechanical comparison of bone marrow aspirate concentrate, micro-fragmented adipose tissue and platelet-rich plasma in prevention of tendon adhesion.

BACKGROUND: Flexor tendon repair often leads to peritendinous adhesions, reducing finger motion and hand function. This study compares the effects of stromal cells from different sources and platelet-rich plasma (PRP) on adhesion formation after tendon repair. METHODS: Forty rabbits had their flexor digitorum profundus tendons transected and repaired with a modified Kessler suture technique. The control group received an isotonic solution. PRP, bone marrow aspirate concentrate (BMAC), and micro-fragmented adipose tissue (MFAT) were injected in groups 2, 3, and 4, respectively. Rabbits wore casts for 2 weeks. Assessments included morphology, histopathology, range of motion (ROM), and biomechanical testing at the 3rd and 8th weeks. RESULTS: At 3 weeks, the BMAC group had the thickest and longest adhesions, the highest Tang Score, and inflammation score. However, at 8 weeks, the BMAC group had the lowest Tang Score and inflammation score. ROM was higher in the PRP group at 3 weeks and BMAC group at 8 weeks. No significant differences were found between BMAC and MFAT groups in adhesion measurements. Biomechanical parameters were higher in BMAC and MFAT groups at 8 weeks compared to control. CONCLUSION: BMAC therapy after primary flexor tendon repair improves adhesion formation and maintains ROM. It also enhances the biomechanical properties of the flexor tendon during the later stages of healing.

Increased Total Antioxidant Capacity Value Improves Survival of Fat Grafts in a Rat Model.

BACKGROUND: While studies aiming to increase fat graft survival continue, in this study, we aimed to investigate the effects of different antioxidants on total antioxidant capacity and their effect on graft survival. METHODS: Thirty-two male Wistar rats were divided into four equally sized groups, including a control group and three antioxidant groups receiving either Melatonin (10mg/kg), Zinc (2mg/kg), or Vitamin E and C (100mg/kg). Autologous fat grafts (1.7± 0.4gr) were transferred to the dorsal subcutaneous region, and total antioxidant capacity was measured on day 0 and 1, week 1 and monthly until the third month. Transferred graft volume and mass (1.3± 0.4gr) were measured using the liquid overflow method and precision scales at the end of the study. Routine hematoxylin-eosin staining and immunohistochemistry against perilipin were performed for semiqualitative analysis and h-score for viable adipose cells, respectively. RESULTS: Collected fat grafts measured significantly less in weight and volume and the survival rate was lower in the control group (p<0.01). Control group exhibited a reduction in TAC, while all groups receiving antioxidants had an increase in TAC during the first week (p=0.02, 0.008, and 0.004 for melatonin, zinc, and vitamins, respectively). Immunohistochemistry of the antioxidant group demonstrated a statistically significant excess and reactivity of cells staining with perilipin antibodies. CONCLUSIONS: In this animal study, the beneficial effect of antioxidants on fat graft survival can be related to the significant increase in TAC following the first week of their administration.

Superior Epididymal Artery-Based Paraepididymal Adipofascial Flap: An Experimental Adipofascial Flap Model in the Rat.

BACKGROUND: Flap surgery is widely performed in reconstructive surgery. Experimental research is vital to improve flap viability. However, the number of flap models for animals is still limited. In this study, we define a new adipofascial flap in rats that can be used to investigate pedicled flap and/or adipofascial flap physiology. METHODS: Eight Wistar male rats were used. Under deep anesthesia, paraepididymal adipofascial flaps were harvested. Flap perfusion was assessed using a near-infrared fluorescence imaging system. The length of the flap and the diameter of the flap pedicle were measured. RESULTS: All animals (n = 8) had sufficient sizes of paraepididymal fat pad, and no animals were lost. The only postoperative complication was testicular hematoma, which was observed in 2 animals. The maximum length of the harvested paraepididymal adipofascial flap was 9.7 cm with a mean of 6.6 cm. The maximum width of the flap was 3.3 cm with a mean of 2.6 cm. The mean pedicle diameter of the paraepididymal adipofascial flap was 1.1 mm. Near-infrared fluorescence imaging revealed adequate perfusion in all flaps. CONCLUSIONS: The number of reported adipofascial flap models in animals is low, and they are mostly limited to flaps based on epigastric vessels. Superior epididymal artery-based paraepididymal adipofascial flap can be used as a pedicled flap model for studies focusing on adipofascial and/or pedicled flap physiology. Uncomplicated surgical technique and short operative time make this flap a valuable alternative to other flap models.

Changing Bacterial Etiology and Antimicrobial Resistance Profiles as Prognostic Determinants of Diabetic Foot Infections: A Ten-Year Retrospective Cohort Study.

Background: In this single-center study, we analyzed a retrospective cohort of patients with diabetic foot infections (DFIs) between 2011 and 2020. Patients and Methods: The first and second five-year periods were compared. A poor prognosis was defined as a primary composite end point including re-infection, major amputation, or mortality at six months. Results: A total of 484 patients were enrolled. Overall, 269 patients had the primary composite end point. A substantial decrease was detected in the second five-year period in terms of re-infection (n = 132, 66.0% vs. n = 68, 23.9%; p < 0.001) and mortality (n = 22, 11.0% vs. n = 7, 2.5%; p < 0.001). A total of 798 micro-organisms were isolated from 484 patients. A substantial increase was detected in polymicrobial infections (48.5% vs. 65.1%; p = 0.001) as well as Streptococcus spp. (2.5% vs. 9.2%; p = 0.003), Corynebacterium spp. (9.5% vs. 22.9%; p < 0.001), and extended-spectrum ß-lactamase (ESBL) producing Escherichia coli (3.0% vs. 12.7%; p < 0.001) in the second five-year period, whereas the prevalence of multi-drug-resistanct (MDR) Pseudomonas aeruginosa (17.0% vs. 10.2%; p = 0.029) and carbapenem-resistant Acinetobacter baumannii (7.5% vs. 2.8%; p = 0.017) decreased. Multivariable regression analysis revealed that MDR Pseudomonas aeruginosa (odds ratio [OR], 1.917; 95% confidence interval [CI], 1.074-3.420; p = 0.028) and carbapenem-resistant Acinetobacter baumannii (OR, 3.069; 95% CI, 1.114-8.453; p = 0.030) were independent predictors for poor prognosis. Conclusions: This 10-year cohort study provides reassuring information about the changing epidemiology of DFIs and the prognostic determinants in patients with DFIs.

Comparison of Real-Time Speech Magnetic Resonance Imagings With Perceptual Speech Analysis in Evaluation Velopharyngeal Sphincter Function.

ABSTRACT: Identifying substantial data and their normative values related to velopharyngeal structures in cleft palate patients may have clinical significance, in order to selection of surgical intervention and prediction of postsurgical outcomes. Previous studies are lack of referring certain anatomic locations or distances that may have affect on speech intelligibility, especially in dynamic state. The aim of this study is to investigate effectiveness of magnetic resonance imagings on the velopharyngeal sphincter function and the correlation with speech intelligibility after functional cleft palate repair. Seventeen patients with repaired cleft palate by single surgeon were enrolled in this study.Quantitative velopharyngeal measures from the oblique coronal plane and midsagittal plane in static and dynamic positions were collected. Patients' speech intelligibility was evaluated by using Pittsburgh Weighted Speech Scale and nasalance score was also measured. Correlation analysis methods were used for evaluating relation between MRI gathered measurements and speech intelligibility scores for determiningconsequential data.Our study shows that the velar knee-posterior pharyngeal wall distance measurement while explosive sound production is the most related data with speech intelligibility. Although future works with more sample number is needed, according to current study the authors think magnetic resonance imagings is a very helpful method in providing reliable information.

Four-Flap Mammaplasty.

BACKGROUND: Any kind of breast shaping aims certain endpoints, and results are expected to be durable. We present a breast shaping technique with an anatomical basis, reproducible and long-lasting results. METHODS: A total of 700 patients have been operated on with this technique. The age of the patients ranged between 18 and 62 with a mean of 33. The follow-up period ranged between 6 months and 15 years with a mean of 18 months. Results have been documented as follow-up notes and digital photography. Subjective rate of satisfaction was estimated by each patient at 6th month follow-up visit as a rating of the overall shape, healing period and final scars from 1 (poor) to 5 (very good). RESULTS: The amount of resection was between 50 and 300 grams (average 190 g) per each breast for mastopexy and 240-670 grams (average 430 g) per each breast for breast reduction. The average change in NAC position at the 6-month follow-up was 3.4 cm ranging between 2.8 and 6.5 cm. In 10 patients (1.4%), hematoma necessitating nonoperative follow-up was observed. In twelve patients (1.7%), wound dehiscence requiring secondary suturing was observed. In 32 patients (4.5%), minor delays in epithelialization were managed with local wound care. In 15 patients, revision of vertical scar was needed. Patients rated their satisfaction with points ranging between 10 and 15 with an average of 13.33. CONCLUSIONS: Four-flap mammaplasty results in good and durable cosmetic results. LEVEL OF EVIDENCE IV: 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 www.springer.com/00266.

Propeller and Pre-expanded Propeller Use of a Transversely Oriented Upper Trapezius Perforator Flap in Head and Neck Reconstruction: Clinical Experience and Review of Vascular Anatomy of the Supraspinal Trapezius Muscle.

Conventionally, trapezius musculocutaneous flap is raised to harbour perforators located inferior to the scapular spine (i.e. 'lower trapezius flap'). In this clinical study, we aimed to use trapezius perforators located superior to the scapular spine to raise a transversely oriented propeller fasciocutaneous flap based on the superficial cervical artery to reconstruct head and neck defects. Patients with head and neck defects who underwent reconstruction with a propeller trapezius perforator flap between August 2014 and October 2019 were evaluated. Demographic data of the patients, topographic data on defects and the flaps were analysed. A total of 14 patients underwent reconstruction with upper trapezius perforator flap with equal gender distribution. Defects were due to tumour resections, burn contractures and exposed foreign materials; located in occipital, temporal, parietal, midfacial and cervical areas; with sizes ranging between 8 × 7 cm and 22 × 19 cm. Overall patient satisfaction was assessed subjectively using a pre-determined set of questions. The sizes of the flaps ranged between 15 × 8 cm - 20 × 9 cm in non-expanded and 26 × 15 cm - 30 × 16 cm in expanded cases. One flap suffered distal superficial flap loss, which was treated with wound care. Follow up period of the patients ranged between 3 and 40 months with an average of 29 months. Using trapezius perforators located above the scapular spine provides thin transversely oriented propeller flaps to be used in head and neck reconstruction. In our series, this flap is further enhanced by pre-expansion for wider uses, e.g. facial resurfacing and releasing neck contractures.

COX2 inhibition in the treatment of COVID-19: Review of literature to propose repositioning of celecoxib for randomized controlled studies.

Coronavirus-triggered pulmonary and systemic disease, i.e. systemic inflammatory response to virally triggered lung injury, named COVID-19, and ongoing discussions on refining immunomodulation in COVID-19 without COX2 inhibition prompted us to search the related literature to show a potential target (COX2) and a weapon (celecoxib). The concept of selectively targeting COX2 and closely related cascades might be worth trying in the treatment of COVID-19 given the substantial amount of data showing that COX2, p38 MAPK, IL-1b, IL-6 and TGF-ß play pivotal roles in coronavirus-related cell death, cytokine storm and pulmonary interstitial fibrosis. Considering the lack of definitive treatment and importance of immunomodulation in COVID-19, COX2 inhibition might be a valuable adjunct to still-evolving treatment strategies. Celecoxib has properties that should be evaluated in randomized controlled studies and is also available for off-label use.

Effects of Insulin, Metoprolol and Deferoxamine on Fat Graft Survival.

BACKGROUND: The main problem faced with fat grafting is unpredictable resorption rates. Many substances have been reported to increase the survival of fat grafts. The aim of this study was to compare the effects of insulin, metoprolol and deferoxamine on fat graft survival. METHODS: Inguinal fat pads of male Sprague-Dawley rats were harvested and split into four parts as grafts. The grafts were placed in subcutaneous pockets in four quadrants on the back area of the rats. The insulin and metoprolol group fat grafts were incubated in regular insulin and metoprolol solutions, until they were placed. Deferoxamine and control group fat grafts were placed without incubation. After surgery, the control group fat grafts were injected with 10 doses of NaCl solution once every 3 days, and the deferoxamine group fat grafts were injected with 10 doses of deferoxamine solution once every 3 days. After a graft maturation period of 3 months, the grafts were harvested for weight measurements and histological and immunohistochemical evaluation. RESULTS: According to the rate of perilipin staining, the metoprolol group had 30% more mature viable adipocytes than the control and insulin group fat grafts (p < 0.05 and p < 0.01, respectively). CD31 activation rates were significantly higher in the deferoxamine and insulin group than in the metoprolol group (p < 0.05). CD34 staining rates did not differ between any groups (p > 0.05). CONCLUSIONS: In this experimental study, we have shown that there was no significantly increased fat graft survival rate seen in any drug treatment group. Low survival rates of stem cells demonstrated that the adipogenesis period ended at 3 months. Treatment of fat grafts with the selective ß1-blocker metoprolol resulted in good quality better graft take with more viable mature adipocytes. However, better viability of adipocytes did not result in increased weight of the fat graft. Studies aiming to compare the effects on fat graft survival of beta-blockers with long or short durations of action, different potencies and different receptor selectivity may be designed in the future. In addition, further studies may be performed, in which immunohistochemical markers used to assess inflammation and fibrosis are added to the study after the completion of the fat graft maturation period at the end of the first year to test the permanence of the results. NO LEVEL ASSIGNED: 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 - www.springer.com/00266 .

Effects of Cigarette Smoke on Fat Graft Survival in an Experimental Rat Model.

INTRODUCTION: A fat graft is the closest thing to being the ideal soft tissue filler. Although it has many advantages, reliability of late-term survival is a never-ending debate. Although there are observational studies that research the effect of cigarette smoke on fat graft take in clinical setting, there has not been an objective experimental animal study on the affect of smoking on fat graft survival. The aim of our study is to search if smoking has an affect on fat grafts. MATERIALS AND METHODS: Twenty-two Sprague-Dawley type rats were used. Exposure was maintained via a passive smoke exposure system. Rats were divided into three groups regarding their exposure period. At the end of the study, transferred fat grafts were extracted and weighed with a precision scale, an arterial blood sample was taken for biochemical analysis, and grafts were sent to the pathology laboratory for immunohistochemical assessment. RESULTS: There were meaningful differences between the control group and the other two groups in graft weight loss, serum cotinine, tissue MDA, adipose tissue/fibrosis ratio, stem cell counts, perilipin positive cell density and inflammation density. Furthermore, we detected meaningful correlations between serum cotinine, tissue MDA and graft weight loss. CONCLUSION: Fat graft takes with the same mechanisms as a wound heals. So like wound healing, cigarette smoke has a negative affect on fat graft survival. A fat graft is by its nature an elective procedure so to improve our late-term success, cigarette smoke exposure should be kept to a minimum for increased reliability. NO LEVEL ASSIGNED: 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 www.springer.com/00266 .

Extended locoregional use of intercostal artery perforator propeller flaps.

Besides conventional flaps, intercostal artery perforator flaps have been reported to cover trunk defects. In this report the use of anterior intercostal artery perforator (AICAP) flap, lateral intercostal artery perforator (LICAP) flap and dorsal intercostal artery perforator (DICAP) flap for thoracic, abdominal, cervical, lumbar and sacral defects with larger dimensions and extended indications beyond the reported literature were reevaluated. Thirty-nine patients underwent surgery between August 2012 and August 2014. The age of the patients ranged between 16 and 79 with a mean of 49 years. The distribution of defects were as follows; 12 thoracic, 8 parascapular, 3 cervical, 8 abdominal, 4 sacral and 4 lumbar. AICAP, LICAP and DICAP flaps were used for reconstruction. Fifty-two ICAP flaps were performed on 39 patients. Flap dimensions ranged between 6 × 9 cm and 14 × 35 cm. Twenty-six patients had single flap coverage and 13 patients had double flap coverage. Forty-six flaps have been transferred as propeller flaps and 6 flaps have been transferred as perforator plus flap. Forty flaps (75%) went through transient venous congestion. In one DICAP flap, 30% of flap was lost. No infection, hematoma or seroma were observed in any patient. Follow-up period ranged between 3 and 32 months with a mean of 9 months. The ICAP flaps provide reliable and versatile options in reconstructive surgery and can be used for challenging defects in trunk.

Fistula tract curettage and the use of biological dermal plugs improve high transsphincteric fistula healing in an animal model.

PURPOSE: The treatment of high transsphincteric fistula is a complex procedure, which may be associated with the risk of recurrence and fecal incontinence. In this study, we used an animal model to compare different types of sphincter-preserving treatments for transsphincteric fistula. METHODS: Sixteen female New Zealand rabbits, weighing 2.8-4.8 kg underwent a surgical creation of high transsphincteric fistula. After 6 weeks, magnetic resonance imaging (MRI) was performed in order to confirm fistula formation and measure the fistula diameter. The rabbits were divided into three groups. Group 1 received no plug treatment (control). Autologous dermal graft and acellular dermal matrix were used as a plug in groups 2 and 3, respectively. Five weeks after treatment, fistula tract healing was determined by measuring the largest fistula diameter with MRI. All rabbits were euthanized and the anorectum excised en bloc for histopathological examination. RESULTS: According to the MRI findings, all groups showed significant healing after the treatment (p < 0.05). The healing rate of fistula diameters after treatment was 40, 66, and 29% in the control, dermal graft, and acellular dermal matrix groups, respectively. In terms of negative healing parameters such as neutrophil, eosinophil, lymphocyte, and plasmocyte accumulation, dermal graft and acellular dermal matrix groups showed significantly lower results than those in the control group (p < 0.05). CONCLUSION: According to MRI and histopathological results, fistula tract curettage and fistula orifice closure improved transsphincteric anal fistula healing. Additionally, in this study, plug treatment favoring autologous dermal graft resulted in better healing.

Locoregional use of lateral thoracic artery perforator flap as a propeller flap.

Although thoracodorsal system is a fundamental source of various flaps, lateral thoracic region has not been a popular flap donor area. There is limited data on the use of lateral intercostal artery perforator flap and lateral thoracic artery perforator flap. In this case series, lateral thoracic artery perforator flap has been used in locoregional (axilla, pectoral region, and arm) reconstruction as an island or propeller flap.Eighteen patients have been operated on between September 2010 and January 2013. The age of the patients ranged between 16 and 68 years with a median of 38 years. A thorough chart review has been performed with preoperative and postoperative photographs. Duration of hospitalization, complication rate and long term results have been documented.Nine patients had severe burn contracture of axilla, 7 patients had axillary hidradenitis suppurativa, 1 patient had giant neurofibroma of arm, and 1 patient had malignant peripheral nerve sheath tumor of pectoral area. Seventeen flaps survived totally, and in 1 flap, distal superficial slough of skin has been observed. No recurrence in hidradenitis or peripheral nerve sheath tumor has been observed. Donor site scar is well hidden in anatomical position. The range of motion of affected extremities returned to normal after reconstruction.Lateral thoracic area provides a reliable flap option with a wide arc of rotation when lateral thoracic artery perforators are used.

Psychiatric disorders and their association with burn-related factors in children with burn injury.

BACKGROUND: The aim of this study was to assess psychiatric disorders and their association with burn-related factors in a population of Turkish children with burns. METHODS: Thirty-one children admitted to the Cerrahpasa Medical Faculty Burn Unit between January 2013 and August 2013 were first assessed by the plastic surgeon, and then those with psychological symptoms were referred to a child psychiatrist, and the records were analyzed retrospectively. RESULTS: The percentage of burned area to Total Body Surface Area (TBSA) ranged between 2-60% (mean, 17.3%). Nineteen patients (61.3%) had a psychiatric diagnosis, which included acute stress disorder (ASD) (n=15), depression (n=3), posttraumatic stress disorder (n=2, comorbid with depression), and delirium (n=1). The percentage of burned area to TBSA was associated with the presence of psychopathology and ASD. Further, psychopathology was associated with the number of burned major body regions. CONCLUSION: Pediatric burn patients are at risk of developing psychopathology. The children with a greater percentage of burned area to TBSA and more burned body regions have the greatest risk of psychopathology. Surgeons have an important role in patient referral for psychiatric interventions, so that psychiatric disorders can be prevented as early as possible.

Use of osseocartilaginous paste graft for refinement of the nasal dorsum in rhinoplasty.

In both primary and secondary rhinoplasty, establishment or refinement of nasal dorsal aesthetic lines is of paramount importance. Many different techniques used to create a cosmetically acceptable nasal dorsum have been published. The material to be used in nasal dorsal contouring should create a harmonic contour and should be easily shaped, long-lasting, and resistant to infection. Resection of the hump yields an osseocartilaginous complex as a single unit when an osteotome is used. Use of a rasp gives a good amount of fragmented material comprising bone, cartilage, soft tissues, and blood. The authors used this material as a paste graft to refine the nasal dorsum in rhinoplasty and retrospectively evaluated the outcomes. A retrospective chart review of 77 patients who underwent this procedure between 2003 and 2009 was performed. The follow-up period ranged from 22 to 40 months (median, 28 months). The postoperative evaluations included clinical examination and digital photographic documentation. The satisfaction of each patient was assessed with a questionnaire completed at the 12th postoperative month. The described graft, which combines the advantages of cartilage and bone, was shown to be clinically durable. This combination also results in an ideal texture and consistency for molding due to its diced form. The texture of this graft enables the surgeon to give a final shape to the nasal dorsum bimanually. In this study, a paste graft was shown to be a versatile and reliable composite material for nasal dorsal contouring and refinement.

A reliable method for treatment of nonhealing ulcers in the hindfoot and midfoot region in diabetic patients: reconstruction with abductor digiti minimi muscle flap.

The foot has a unique anatomic composition and a perfect architecture, which is necessary for mobilization. However, this complex structure is also responsible for healing problems in foot reconstruction. After 25 years of experience in diabetic foot surgery practice, we observed that some hindfoot ulcers are like an iceberg in that they have much more involvement in the plantar fat pad than the skin, and the lateral midfoot region is a common site for ulcer formation. Also the fifth tarsometatarsal joint region is a prominent anatomic structure vulnerable to repetitive trauma and ulcer formation that may easily spread to other parts of the foot. These ulcers should be reconstructed with well-vascularized tissues such as muscle flaps after debridement. Between 2003 and 2010, 17 diabetic patients with foot ulcers, involving bone and joint, were reconstructed with abductor digiti minimi muscle flap. When it is needed, the flap is covered with a small split-thickness skin graft. In all cases, complete healing was achieved. The muscle flap functioned well as a versatile and shock absorbent coverage without recurrence of the ulcer during a mean follow-up period of around 2 years. Diabetic foot ulcers should be evaluated and treated individually depending on their location and affected tissue composition. The most appropriate reconstructive option should be selected for each lesion. The abductor digiti minimi muscle flap is extremely useful for the reconstruction of small- to moderate-sized defects that have exposed bone, joint, or tendons in the hindfoot and lateral plantar midfoot.