Blunt Trauma Induced Closed Femoral Bone Fracture in a Rat Model: Are Vessels Safe to Use for Microsurgery? Further Insight into the Zone of Injury Concept.

BACKGROUND: The study aims to investigate the zone of injury for major vessels after high-velocity traumas, as it is unclear whether avoiding vascular structures is necessary during microvascular anastomosis or how long it takes for them to be used again. METHODS: This study uses Doppler ultrasonography and a rat model to evaluate the histopathological changes and flow velocity of major vessels in the zone of injury after high-velocity trauma with closed femoral bone fracture. Osteosynthesis was performed using an intramedullary wire. Samples were collected from day 3 and week 3. The unaffected contralateral side is used as control. RESULTS: Results from arterial and venous flow assessments showed no evidence of ischemia in the extremities. Both arteries and veins were patent in both intervals and on the control side. The evaluation of the vessels showed arterial injury with a slightly reduced arterial flow on day 3 and week 3. The venous flow was slightly reduced on day 3 but not on week 3. Statistically, arterial endothelial injury was higher on day 3 than on week 3 (p = 0.006). Media inflammation was also higher on day 3 (p = 0.06). Arterial endothelization distribution was higher in week 3 (p = 0.006). No significant differences were found in arterial media irregularity, necrosis, platelet aggregation, bleeding, and wall rupture. Venous samples showed no significant differences in any parameter (p < 0.05). CONCLUSION: High-velocity trauma increases the risk of thrombosis in vessels. Intravascular repair can start on day 2 and continue till week 3 with significant endothelization. Although physiologic findings do not alter arterial or venous flow, histologic findings support vessel injuries leading to potential complications. Microsurgery should be considered out of the injury zone until adequate vessel healing is achieved.

Ligasure-assisted submandibular gland excision in deep plane neck lift: review of 83 patients.

BACKGROUND: In performing a neck lift, the size and location of the submandibular gland (SMG) must be evaluated to achieve the ideal neck contour. Many surgeons, however, avoid SMG excision because of the technical difficulty, risks of hematoma, and nerve damage. LigaSure™ (Valleylab, Boulder, CO) is a bipolar energy-based instrument that permanently seals vessels and connective tissue which can make the SMG excision step easy and safe by reducing surgical risks. METHODS: A total of 83 patients who underwent SMG excision between 2018 and 2022 were included in the study. All patients' SMGs were partially excised by LigaSure™ (LS), and the complication rates were documented. RESULTS: Patients were followed up for an average of 21 months (9 months-2.4 years). No perioperative intraglandular bleeding or postoperative hematoma was observed in any of the patients. No sialoma was observed in any of the patients postoperatively. Only three patients underwent repeated seroma aspirations. Transient lower lip weakness was observed in 7 patients which all recovered in the first 6 months postoperatively. CONCLUSIONS: LS-assisted SMG excision in deep neck lift surgery was found to be technically easier, time-saving, safe, and highly effective in preventing hematoma and intraoperative bleeding.

Abdominoplasty with Circumferential Liposuction: A Review of 1000 Consecutive Cases.

BACKGROUND: The authors present the technique called "abdominoplasty with concurrent circumferential liposuction," where the whole trunk is addressed as a single aesthetic unit. METHODS: Between January of 2008 and June of 2016, abdominoplasty with circumferential liposuction was performed in 1000 patients (984 women and 16 men) by the senior author. Patients had a mean body mass index of 27.5 kg/m (range, 18.1 to 34.5 5 kg/m). Liposuction was performed circumferentially and the abdominal flap was detached up to the costal margins. Simultaneous fat grafting was also performed if required. Outcomes and complications were documented. RESULTS: Traditional abdominoplasty incisions were used in 359 patients, whereas extended incisions were used in 641 patients. The mean duration of follow-up was 27 months (range, 12 days to 61 months), and the mean duration of surgery was 154 minutes (range, 109 to 260 minutes). The mean amount of simultaneously aspired supernatant lipoaspirate was 1940 cc (range, 1700 to 4580 cc). Simultaneous gluteal fat grafting was performed in 34 percent. None of the patients had any skin necrosis. The most common complication was seroma (19 percent). CONCLUSIONS: In abdominoplasty, the entire central body should be considered as a single unit. Circumferential widespread liposuction with standard undermining of the abdominal flap up to the costal margins is safe and yields superior aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Assessment of the Relationship Between Clinicophysiologic and Magnetic Resonance Imaging Findings of the Temporomandibular Disorder Patients.

Temporomandibular joint disorders (TMJDs) are a complex group of disorders that comprise dysfunctions of the temporomandibular joint (TMJ). In this study, we analyzed the objective and subjective findings of the TMJD patients by using Helkimo anamnesis (Ai) and clinical dysfunction (Di) indices, and tried to document a relation between these findings and magnetic resonance imaging (MRI) results.Ninety-eight patients who were admitted to our clinic were included in the study. The clinical evaluation was performed by using Ai, an 8-question-survey based on the objective symptoms of patients; Di, concluded as the score of 5 objective measurements of physical examination. The morphology of the TMJ was evaluated by MRI, and the findings were analyzed and statistically compared with respect to the Di.The most commonly seen symptoms were noise during mandibular movement (58%), pain around the joint (42.5%), and pain with mandibular movements (40%). Seventeen patients (17.3%) were Di0, 47 (48%) were DiI, 24 (24.5%) were DiII, and 10 (10.2%) were DiIII. Thirty-seven patients (37.8%) had abnormal MRI findings, whereas 61 patients (62.2%) had normal MRI. The most commonly encountered pathology was anterior disc displacement with reduction, which was reported in 15 patients. Increased TMJ Di, which points a more progressed TMJD, was found to be significantly related with the pathological MRI findings (P < 0.05).MRI is especially effective in particularly those with high Di; therefore, the results of the study may give a prospect in which types of patients does MRI give a valuable data toward diagnosis, in which stages of the TMJD should we expect pathological findings, and thereby preventing unnecessary use of MRI in patients with symptoms of TMJD.

The Effects of Mucoperichondrial Flap Elevation on Septal L-Strut Cartilage: A Biomechanical and Histologic Analysis in a Rabbit Model.

BACKGROUND: The harvesting of septal cartilage following mucoperichondrial flap elevation has almost become a standard step in rhinoplasty. However, the strength of the remaining septum has not yet been evaluated. In the current experimental study of a rabbit rhinoplasty model, the remaining septum following a graft harvest was analyzed both biomechanically and pathologically. METHODS: Forty New Zealand rabbits were classified into four equal groups. Group 1 consisted of the animals in which unilateral elevation of the mucoperichondrial flaps was undertaken before the graft harvest, group 2 consisted of the animals in which bilateral elevation was undertaken, group 3 included the animals where the septum was exposed and left untouched after a bilateral mucosal flap elevation, and group 4 was designated as the control group. Specimens were analyzed under light microscopy for multiple parameters. Biomechanical analyses were performed with a universal testing device at the Department of Engineering, Biomechanical Laboratories, Istanbul Technical University. RESULTS: Biomechanical analysis in terms of maximum tension revealed significant results among the groups (p = 0.008). Although insignificant results were observed overall using a pathologic analysis, the amount of chondrocytes was lower in group 2 than in group 1 (p = 0.099). The amounts of matrix collagen (p = 0.184) and fibrosis were (p = 0.749) higher in group 2 than in group 1. CONCLUSIONS: From these data, the authors conclude that mucoperichondrium integrity plays a crucial role in the biomechanical strength of the septum. More sophisticated studies with further pathologic analysis are required to determine the exact mechanism of strength loss observed with mucoperichondrial flap elevation.

Optimal treatment of zygomatic fractures: a single-center study results.

OBJECTIVES: This study aims to investigate the epidemiological and operative characteristics of patients undergoing surgery for zygomatic fractures. PATIENTS AND METHODS: Between May 2008 and October 2013, a total of 121 patients (98 males, 23 females; mean age 27 years; range, 9 to 63 years) who were operated for zygomatic fractures in our clinic were retrospectively analyzed. Age and sex of the patients, symptoms, fracture and incision sites, length of hospital stay, plate type, treatment options, and complications were recorded. RESULTS: Assault was the leading cause of trauma (39%), followed by traffic accidents (24%). The most common symptom or clinical sign was the periorbital ecchymosis/hematoma. Conservative treatment was applied in 14 patients (12%). Surgery was performed with a closed reduction in 17 patients (14%) and open reduction in 90 patients (74%). The most common fracture site was the infraorbital rim in 76 patients (62.8%). A total of 48% patients had three-site, 35% had two-site and 12% had one-site of fixations. The major material used for the orbital floor reconstruction was porous polyethylene in 43.7% patients. CONCLUSION: Our study results show that surgery is required in the majority of the patients with zygomatic fractures. However, further large studies are required to determine many parameters such as incision sites, plate locations, and the material to be used in orbital floor reconstruction.

Diced Cartilage Grafts Wrapped in Rectus Abdominis Fascia for Nasal Dorsum Augmentation.

BACKGROUND: Dorsum augmentation is one of the most delicate components of rhinoplasty. Although various solid grafts have been used in the past for this purpose, diced cartilage grafts wrapped in fascia have become popular in recent decades. In this study, the authors analyze and discuss the results of using diced cartilage grafts wrapped in rectus abdominis muscle fascia for dorsal augmentation. METHODS: Nasal dorsum augmentation using the diced cartilage wrapped in rectus abdominis fascia technique was performed on 109 patients between 2008 and 2014. Six patients were primary cases, 69 patients were secondary, and 18 were tertiary. Sixteen patients had previously undergone more than three operations. In all patients, the rectus abdominis fascia was harvested with the described technique and wrapped around the diced cartilages obtained from the costal cartilage. RESULTS: The average follow-up period was 19.6 months (range, 6 to 47 months). Satisfactory results were obtained with acceptable complications and revision rates. Three patients underwent reoperation because of overcorrection. Insufficient augmentation was seen in five patients. In four patients, infection developed after postoperative day 5. One patient complained of a hypertrophic scar on the donor site. None of the patients showed any symptoms indicating an abdominal hernia. CONCLUSIONS: Techniques using diced cartilage grafts wrapped in fascia have now become the gold standard for dorsal augmentations. When it is considered that secondary cases requiring dorsal augmentation are usually those also needing costal cartilage grafts, rectus abdominis fascia becomes a useful carrier for diced cartilages, which is in the same donor area. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Five-Years Trigger Finger Due to Partial Flexor Tendon Laceration in a Child.

Trigger finger (TF) is a condition that affects quality of life and one of the most common causes of hand pain and disability. TF is characterized by catching, snapping or locking of the involved finger flexor tendon, associated with pain. TF in the children occurs rarely than in adults and partial tendon laceration is an uncommon cause of TF in the children. Thus, our aim in this study to define TF due to partial flexor tendon laceration in a child.

Effects of Fatigue and Sleep Deprivation on Microvascular Anastomoses.

Previous studies have investigated the effects of various human-based factors, such as tremor, exercise, and posture, on microsurgical performance. In this study, the authors investigated the effects of sleep deprivation and fatigue on microsurgery. A total of 48 Wistar Hannover rats were divided into 3 groups (16 anastomoses in each group) to be operated on at 3 different times: in the morning at 08:00 hours (group I), at night on the same day (01:00 h, group II), and the next morning at 09:00 hours (group III) following a night with no sleep. The blindly evaluated parameters were anastomotic times, error score (ES), global rating scale (GRS), autopsy scores (ASs), and patency. There was progressive decrease in the anastomosis times between the groups (P > 0.05). The patency rates were 93% in group I, 81% in group II, and 81% in group III (P > 0.05). The ES (P < 0.01), AS (P < 0.001), and GRS (P < 0.001) revealed significant results. Comparison between the groups showed that other than the anastomosis time, the night group (group II) showed a significant drop when compared with the preceding morning group (group I) (ES P < 0.01, AS P < .001, and GRS P < 0.001). In most of the parameters, the errors occurred with fatigue after the day and reached a maximum at the end of the day (group II). This study provides valuable data that might have significant medicolegal implications for controversial issues. More studies, however, including multiple surgeons with different experience levels, might be required to fully elucidate the overall effects of fatigue and sleep deprivation on microsurgery.

The Use of Dermabrasion to Achieve Natural-Looking Areolas Following Breast Reduction or Mastopexy: A Study of 23 Patients.

BACKGROUND: Although obtaining symmetrical breasts with good projection and a correctly positioned nipple-areola complex are the main objectives after breast reduction (BR) or mastopexy (MP), the importance of areola esthetics should not be underestimated. In this study, the authors discuss the use of dermabrasion for another purpose, which is to achieve a more natural areola with a smooth, natural border and depigmentation. METHODS: Twenty-three patients who had undergone BR surgery (18) or MP (5) between 2012 and 2014 were included in the study. The mean age of the participants was 25.5 (range 19-43). Dermabrasion of the areola was performed using a diamond-type fraise to obtain a smooth transition from the border of the areola to the depigmented areola zones. RESULTS: The patients were followed up for 15 months on average (range 12-18 months). In a survey administered 1 year after surgery, the patients were asked to score their new areola on a scale of 0-10. The mean score was 8.6 (range 4-10). Three patients were re-operated due to the persistence of the sharp border due to insufficient dermabrasion. One patient had a hypertrophic scar and another had hyperpigmentation. CONCLUSIONS: Satisfactory and a more natural areola can be obtained using dermabrasion with few complications in BR or MP patients. Therefore, this technique may be considered a complementary procedure for motivated and voluntary patients ready to accept the disadvantages of a secondary procedure.

Autologous fat injection into the pectoralis major as an adjunct to surgical correction of gynecomastia.

BACKGROUND: Correction of gynecomastia in males is a frequently performed aesthetic procedure. Various surgical options involving the removal of excess skin, fat, or glandular tissue have been described. However, poor aesthetic outcomes, including a flat or depressed pectoral area, limit the success of these techniques. OBJECTIVES: The authors sought to determine patient satisfaction with the results of upper chest augmentation by direct intrapectoral fat injection in conjunction with surgical correction of gynecomastia. METHODS: In this prospective study, 26 patients underwent liposuction and glandular excision, glandular excision alone, or Benelli-type skin excision. All patients received intramuscular fat injections in predetermined zones of the pectoralis major (PM). The mean volume of fat injected was 160 mL (range, 80-220 mL per breast) bilaterally. Patients were monitored for an average of 16 months (range, 8-24 months). RESULTS: Hematoma formation and consequent infraareolar depression was noted in 1 patient and was corrected by secondary lipografting. Mean patient satisfaction was rated as 8.4 on a scale of 1 (unsatisfactory) to 10 (highly satisfactory). CONCLUSIONS: Autologous intrapectoral fat injection performed simultaneously with gynecomastia correction can produce a masculine appearance. The long-term viability of fat cells injected into the PM needs to be determined. LEVEL OF EVIDENCE: 4 Therapeutic.

Foot ischemia after a free fibula flap harvest: immediate salvage with an interpositional sapheneous vein graft.

The most dreaded major donor-site complication of free fibula flap is a foot ischemia, which is fortunately rare. Various authors have discussed the efficacy of the use of preoperative imaging methods including color Doppler, magnetic resonance angiography, and conventional angiography. A 25-year-old man presented with a 10-cm mandibular defect after a facial gunshot injury. Lower extremity color Doppler revealed triphasic peroneal, tibialis anterior, and posterior artery flows. A fibula osteocutaneous flap was harvested, and the mandible was reconstructed. However, the suture sites at the donor site began to demonstrate signs of necrosis, abscess formation, and widespread cellulitis beginning from postoperative day 9. Angiogram of the lower extremity on the 13th day demonstrated no flow in the right posterior tibial artery distal to the popliteal artery, whereas the anterior tibial artery had weak flow with collateral filling distally. An emergency bypass with a saphenous vein graft between the popliteal artery and the distal posterior tibial artery was performed. Repeated debridements, local wound care, and vacuum-assisted closure were applied. A skin graft was placed eventually. The extremity healed without severe functional disability. In conclusion, although the arterial anatomy is completely normal in preoperative evaluation, vascular complications may still ocur at the donor fibula free flap site. In addition, emergency cardiovascular bypass surgery, as we experienced, may be necessary for limb perfusion.

The free-nipple breast-reduction technique performed with transfer of the nipple-areola complex over the superior or superomedial pedicles.

BACKGROUND: Although the free-nipple breast-reduction technique is essentially an amputation, achieving aesthetic results still is important. The authors present their technique for free nipple-areola complex (NAC) transfer over the superomedial or superior pedicle full-thickness flaps in patients for whom a free-nipple technique is inevitable due to certain risk factors. METHODS: The study included 25 patients who underwent surgery with the aforementioned method for addressing severe gigantomastia. The patients had a mean age of 43 years (range 34-59 years) and a mean body mass index (BMI) of 35.8 kg/m(2) (range 28-42 kg/m(2)). During the operation, the NAC was elevated as a full-thickness skin graft, then transposed to the superior or superomedial pedicles, which had been planned previously. The subsequent stages of the operation thus became a Wise-pattern breast reduction. RESULTS: The mean resection per breast was 1,815 g (range 1,620-2,410 g). Breast projection, shape, and areolar pigmentation were assessed during the follow-up visit. One patient experienced a partial loss of the NAC graft, which healed secondarily, and three patients experienced a patchy hypopigmentation of the NAC. Breast projection and conical structure were observed to be preserved during the follow-up period. CONCLUSIONS: The modified free-nipple technique aimed to convert the reduction procedure to a technique similar to pedicle methods, yielding successful results during the early phases. The full-thickness flap constructed in this way provides more fullness and a maximum contribution to projection in patients who will inevitably undergo breast reduction with the free-nipple method. 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 .

Functional outcomes of preauricular underparotid retrograde approach for mandibular condyle fractures.

Management of condyle fractures includes a wide spectrum of alternatives including analgesia alone, physiotherapy, intermaxillary fixation, and open reduction and internal fixation. Various approaches have been previously mentioned for the access to the mandibular condyle. The aim of this retrospective clinical study was to evaluate our clinical results on preauricular underparotid retrograde approach for condylar fractures. This retrospective study included 20 condylar fractures in 16 patients who were treated surgically using a preauricular transparotid retrograde approach between 2010 and 2013. Functional outcomes with this method were addressed in light of the results obtained in this clinical series. We suggest this method in the management of condylar fractures.

Is there a profit to use the lateral antebrachial cutaneous nerve as a graft source in digital nerve reconstruction?

BACKGROUND: The digital nerves are commonly injured in emergency hand surgery practice. Lateral antebrachial nerve is of the autologous graft options available in forearm for digital nerve reconstruction. In this report, we aimed the evaluation of this nerve as an autologous nerve source for digital nerve repair. PATIENTS AND METHODS: The overall sensorial results of the lateral antebrachial cutaneous nerve grafting and associated donor site morbidity in neglected digital nerve injuries of 15 patients in Zones 1 and 2 were evaluated Average length of the harvested lateral antebrachial cutaneous nerve grafts was 1.81 cm (0.75-3 cm.). RESULTS: Patients have been followed up for 20.7 months in average (range: 9.3-41 months). According to Highet and Sander criteria modified by Mackinnon and Dellon, nine patients were graded as S4, whereas six patients had S3+ values. According to modified ASSH guidelines for stratification of static 2PD results, excellent results were obtained in five patients, good results were achieved in eight patients and moderate results were obtained in two patients. Both the donor and recipient sites were evaluated with Semmes-Weinstein monofilament tests where satisfactory results have been obtained. Only two patients reported minimal cold intolerance at the donor site apart from the mild hypoesthesia noted at the anterolateral aspect of the middle forearm. CONCLUSION: Quite favorable clinical results with minimal donor site sensorial deficiency, anatomical and histomorphological similarity and being available in close location to surgical area brings up a matter to utilization of LABCN for digital nerve reconstruction.

"Three-suture technique" for estimation of the intraoperative maneuvers in rhinoplasty.

Rhinoplasty is one of the most challenging procedures to master in plastic surgery. A successful outcome almost always requires a detailed preoperative analysis. However, intraoperative assessment should not be underestimated as well. To give a rough idea about the changing positions of the basic landmarks of the nose, we would like to demonstrate the "3-point suture determination" test. With this simple method, surgeons might estimate the instant effects of certain maneuvers during surgery.