Simultaneous repair of cutaneous and subcutaneous wounds using a single suture technique.

OBJECTIVE: To describe a single suture technique for the simultaneous repair of cutaneous and subcutaneous wounds. METHOD: Skin and subcutaneous wounds of >3cm in size were repaired using a single suture technique. Different suture sizes were chosen for different wounds. Timing of suture removal was decided according to body area and wound healing status. RESULTS: A total of 78 patients were treated (41 women and 37 men). Mean age was 31.7 years (range: 14-72 years). At one month postoperatively, 56 patients attended a follow-up visit and 27 patients attended at six months postoperatively. Local infection was observed in one patient and wound dehiscence observed in two patients after suture removal. Resulting scars were similar to those of other types of suture techniques. CONCLUSION: This study describes a single suture technique for the simultaneous repair of cutaneous and subcutaneous wounds. It is easy to learn and perform. This technique reduces the risk of infection, cost and procedure time.

Tamoxifen-Related Thrombosis: An Experimental Study in Rat Venous Microvascular Anastomosis Model.

Tamoxifen is an estrogen receptor modulator and has been shown to increase risk for microvascular flap complications. This study aimed to investigate the clinical and histopathological effects of tamoxifen use in venous microvascular anastomosis model in rats. The role of vitamin E combination therapy and discontinuing tamoxifen therapy preoperatively were also evaluated.Forty rats were equally divided into 4 groups as follows: group 1 was given saline by oral gavage, group 2 was given tamoxifen citrate, group 3 was given tamoxifen citrate and vitamin E, and in group 4, tamoxifen citrate was given everyday except between days 12 and 16. In each group, femoral veins were dissected in each side and end-to-end anastomosis was performed in one side. Clinical and histopathological evaluations were performed. The ratio of total endothelial area to total vein area in a cross-sectional view of the vein was evaluated and compared.All veins with anastomosis in postoperative 15 minutes were found to be patent. In postoperative 1 week in groups 1 to 4, visible thrombus were present in 1, 3, 2, and 3 samples, respectively. Vitamin E group showed similar histopathological findings with control group. The ratio of endothelial layer to total vein cross-sectional area was increased in groups 2 and 4 in all samples. The increase was statistically significant between groups 2NA and 3NA (P = 0.023) and 2A and 1A (P = 0.006).Chronic tamoxifen consumption in the presence of anastomosis have led to prominent endothelial proliferation in rat femoral veins. Vitamin E combination therapy reversed this endothelial proliferation and should be focused in future studies.

A New Technique for Correction of Tethered and Depressed Scars: Layered Dermal Support.

BACKGROUND: Many methods have been used for correcting tethered and depressed scars, but most of these methods have had unsatisfying results and ended up with recurrence. The aim of this study is to present a new surgical technique that overcomes these problems. MATERIALS AND METHODS: Twenty-two depressed scars were corrected using the layered dermal support technique. With this technique, the depressed part of the scar is deepithelialized and used in a layered fashion to support the skin flaps. RESULTS: All of the patients were evaluated 1 year postoperatively. There was no recurrence of tethering or depression. CONCLUSION: The layered dermal support technique is a relatively quick procedure that uses only basic plastic surgery principles. It offers a good solution for the correction of tethered and depressed scars without recurrence. 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 www.springer.com/00266 .

An emerging etiological factor for hand injuries in the pediatric population: public exercise equipment.

OBJECTIVE: The purpose of this study was to describe the role of public exercise equipment in pediatric hand traumas as a preventable etiological factor. METHODS: Pediatric patients with hand injuries referred from the emergency department were evaluated retrospectively. Age and gender of the patients, timing, etiology, mechanism of hand trauma, localization of the injury, diagnoses of the patients, and hospitalization rates were reviewed. RESULTS: Amongst the 310 pediatric patients evaluated, 31 patients (10%) experienced injury related to public exercise equipment. Within this group of patients, most were between 5 to 9 years of age, and all injuries were blunt and crush type. Lacerations and fractures were the main diagnoses. Complex injuries that required inpatient care were reported in 19.3% of the patients. CONCLUSION: Public exercise equipment-related injuries are increasingly prevalent in pediatric hand traumas. Preventive actions such as shielding the moving parts should be taken to reduce these rates.

Clinical Experience With the Combination of a Biceps Femoris Muscle Turnover Flap and a Posterior Thigh Fasciocutaneous Hatchet Flap for the Reconstruction of Ischial Pressure Ulcers.

BACKGROUND: The reconstruction of ischial pressure ulcers is problematic because of the distinctive anatomical properties of the region and high recurrence rates. To date, no single technique has been proven to be effective in reducing recurrence of the ulcers. We present our experience with the combination of a biceps femoris muscle turnover flap and a posterior thigh fasciocutaneous hatchet flap and discuss the long-term results. METHODS: A retrospective clinical analysis of 15 patients with grade 4 ischial pressure ulcers reconstructed with biceps femoris muscle turnover flaps and laterally based posterior thigh fasciocutaneous hatchet flaps was carried out between January 2010 and January 2013. Debridement and reconstruction of the ulcers were accomplished in a single stage. The posterior thigh fasciocutaneous flap was elevated in a hatchet style. The long and/or short head of the biceps femoris muscle were dissected from their insertions, turned over on their major pedicles, and their distal portions were used to obliterate the cavitary defect. The skin defect over the muscles was covered by the fasciocutaneous hatchet flap. The average age of the patients was 42.6 years and the mean follow-up time was 27.2 months. RESULTS: Three patients had the following early postoperative complications: hematoma, suture dehiscence, and the necrosis of the short head of biceps muscle. Only 1 patient had a recurrent ulcer 15 months after surgery, which was treated with debridement and the readvancement of the fasciocutaneous flap. The overall recurrence rate was 6.6%. CONCLUSIONS: The biceps femoris muscle turnover flap combined with the posterior thigh fasciocutaneous hatchet flap is a worthwhile option to consider for the reconstruction of ischial pressure ulcers and this technique produces favorable results in terms of the lack of recurrence and complications. The use of the muscle and fasciocutaneous tissue as 2 different flaps, which have different roles in the early and late postoperative period, reduces the recurrence rate.

Selective Nerve Block Combined With Tumescent Anesthesia.

PURPOSE: To evaluate the effect of selective nerve blocks before tumescent anesthesia on the pain and anxiety levels of patients. METHODS: A prospective study was performed with 80 patients. Forty consecutive patients received tumescent anesthesia, and 40 consecutive patients received selective nerve blocks followed by tumescent anesthesia. Patients filled out a questionnaire regarding their preoperative, intraoperative, and postoperative pain and anxiety levels. The results of the questionnaire were evaluated with an independent samples t test. RESULTS: The 2 study groups showed similar distribution in age, sex, and diagnosis. No complications related to tumescent anesthesia or nerve blocks were observed. The group that received tumescent anesthesia with selective nerve blocks reported lower pain scores in anesthesia injections than the group that received tumescent anesthesia alone. The intraoperative and postoperative pain and anxiety levels between the groups were not different. CONCLUSION: Tumescent anesthesia combined with selective nerve blocks in hand surgery decreased the pain associated with injections and increased patient satisfaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

The ultrasonographic evaluation of hemodynamic changes in patients with diabetic polyneuropathy after tarsal tunnel decompression.

BACKGROUND: Nerve decompression procedures have shown to have promising roles in patients with diabetic polyneuropathy. It is known that not only nerves but also arteries pass through the same compressed anatomical tunnels. The aim of the study is to reveal whether the surgical decompression procedures have a positive effect on hemodynamic and morphological parameters of the arterial structures passing through these anatomic tunnels. METHODS: Twenty-seven patients who underwent posterior and anterior tarsal tunnel release procedures were retrospectively scanned for preoperative and 3 months postoperative arterial Doppler ultrasound imaging. The preoperative and third month postoperative measurements were compared for flow pattern of artery, flow lumen diameter, pulsatility index (PI), resistance index (RI), and flow volumes by evaluating the hemodynamic and morphological parameters of dorsalis pedis (DPA) and tibialis posterior arteries (TPA). RESULTS: For TPA, mean PI values were 5.76 ± 2.78 preoperatively, 7.17 ± 3.08 postoperatively. Mean RI values were 0.94 ± 0.04 preoperatively and 0.89 ± 0.05 postoperatively. For DPA, mean PI values were 5.06 ± 2.14 preoperatively and 6.35 ± 2.31 postoperatively. Mean RI values were 0.93 ± 0.05 preoperatively and 0.86 ± 0.06 postoperatively. When the results are analyzed for both of the arteries, PI values were significantly increased; RI values were significantly decreased when the preoperative measurements were compared with the postoperative measurements (P < 0.05). CONCLUSION: According to these results, it can be suggested that the nerve release procedures have a positive effect on the hemodynamic and morphological parameters of the arteries as they pass through the anatomical tunnels as well as its positive effects on the neurological functions of the entrapped nerves.

Hatchet Flap: Clinical Evaluation of Results in Reconstruction of Lateral Nasal Region Defects.

Hatchet rotation-advancement flap is a well-known flap design, which is a worthwhile option in the reconstruction of lateral nasal region skin defects. In this study, the author's experience with 3 different designs of hatchet flaps, for the reconstruction of the defects in 3 different parts of the lateral nasal region, has been presented. All flaps in 31 clinical cases were planned from the cheek and nasolabial region. For the defects in the upper 1/3 part, flaps were planned in advancement type, for the middle 1/3 part, flaps were planned in rotation-advancement type, and for the lower 1/3 part, flaps were planned in rotation type. Satisfactory results were achieved in all patients except in patients having defects in the lower 1/3 part. In reconstruction of lateral nasal region defects, hatchet flap has different advantages such as versatility, better tissue match, and short final scar in the nasolabial fold. When planned in rotation type, for the lower 1/3 part, the ratio of complications increases significantly, which necessitates considering other flap options as the first-line choice of reconstruction for this region.

Comparison of the histopathological findings of patients with diabetic and idiopathic carpal tunnel syndrome.

PURPOSE: This study is aimed to investigate whether there are any histopathological differences between diabetic and idiopathic carpal tunnel syndromes. METHODS: The biopsy specimens were taken from transverse carpal ligament (TCL), tenosynovium adjacent to median nerve and epineurium of median nerve and evaluated in 47 patients (21 diabetic and 26 idiopathic) who were diagnosed with carpal tunnel syndrome (CTS) and treated surgically with open carpal tunnel release. Fibroblast proliferation, fibrosis, perivascular inflammation, oedema, vascular proliferation and vascular wall thickness were determined and scored in all specimens. RESULTS: There weren't any histopathological abnormalities in TCL specimens of both groups. Synovial hyperplasia, fibrosis and perivascular inflammation were not observed in tenosynovial analysis of both groups. Diabetic CTS patients, when compared with idiopathic CTS patients, had higher rates of synovial edema (idiopathic CTS 57 %, diabetic CTS 87 %), vascular proliferation (idiopathic CTS 30.8 %, diabetic CTS 90.5 %) and increased vascular wall thickness (idiopathic CTS 11.5 %, diabetic CTS 90.5 %). There was no oedema, fibrosis and perivascular inflammation of the epineurium in specimens of either group. But increases in vascular proliferation (idiopathic CTS 7.7 %, diabetic CTS 71.4 %) and vascular wall thickness (idiopathic CTS 3.8 %, diabetic CTS 71.4 %) was seen in the epineurium of diabetic patients and these differences were statistically significant (p < 0.05). CONCLUSION: Because of the severe synovial and epineurial histopathological abnormalities and inadequate neural regeneration capacity, surgical open carpal tunnel decompression should be planned earlier in diabetic CTS patients. Further studies should be considered to evaluate the histopathological features of diabetic CTS patients early in the course of the disease.

Basal cell carcinoma of the head and neck region: a retrospective analysis of completely excised 331 cases.

The aim of the study is to analyze all completely excised BCCs in the head and neck region with regard to age, sex, personal and familial history, skin type, tumor localization and size, histopathological subtype of tumor, reconstruction method, and recurrence rates. Incompletely excised BCCs were not included in this study since incomplete excision is the most important preventable risk factor for recurrence. In 320 patients, 331 lesions were retrospectively evaluated by dividing into the following 8 subunits: scalp, frontotemporal, orbital, nose, cheek, auricula, perioral, and chin-neck area. Most of the patients were in 60-70 age group (34.7%). The nose (32.3%) was the most common site of presentation. Clinically, all lesions and, histopathologically, most of the lesions (42.2%) presented were of the nodular type. All cases of recurrence after complete excision (n = 9, 2.7%) were located in the median parts of the head and neck region and were mainly diagnosed histopathologically as sclerotic and micronodular. Even though completely excised, head and neck region BCCs, especially which are more prone to recurrence due to anatomical and histopathological properties, should be more closely monitored in order to decrease morbidity and health care costs.

Inverted nipple correction with dermal flaps and traction.

BACKGROUND: Inverted nipple occurs when part of or the entire nipple is abnormally located below the areola. Surgical repair of severe cases involves suture or flap techniques. Complications include recurrence, lactation problems, hypopigmented scar formation in the areola, and loss of sensation. We describe an alternative repair technique using a dermal flap and traction, which leads to less apparent scarring and preserves lactation function and sensation. METHODS: Between January 2010 and January 2013, we treated 28 inverted nipples in 16 patients using two areola-based triangular dermal flaps and traction. The scar was aligned with the junction of the nipple and the areola. Postoperatively, traction was applied through an apparatus prepared from a 50-cc syringe. Patients were followed up for 8-24 months (mean = 16.5 months). RESULTS: Adequate projection was achieved in all patients and no wound dehiscence or complications such as infection occurred. Unilateral recurrence occurred in one patient on the 10th postoperative day. This patient was reoperated on successfully using the same method. No loss of sensation was observed in any of the patients during the postoperative period. CONCLUSIONS: This dermal flap technique for treating inverted nipple was effective and preserved lactation function. The alignment of the scar with the junction of the nipple and the areola led to a more aesthetic appearance with no apparent scarring. The traction method helped maintain traction for a longer period, which in our opinion increased the success rate of the surgery. 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 www.springer.com/00266.

Tongue flap as a reconstructive option in intraoral defects.

The reconstruction of intraoral defects can be challenging due to the different characteristics of the region, importance of preserving the anatomy and function, and shortage of available donor areas. The location and size of the defect guides the reconstructive surgeon through the treatment plan. Among the options available, tongue flaps have been found useful in intraoral defect reconstruction.In this study, we presented the use of tongue flaps in different kinds of intraoral defects, and compared the advantages and disadvantages with other methods. Between 2004 and 2011, tongue flaps were used in intraoral reconstruction of 11 patients (6 male and 5 female) with a mean age of 30.1. Six patients had palatal fistula, 3 had alveolar region and mouth floor defects, and 2 had lower lip defects. All of the tongue flaps planned were anterior based, 6 dorsal and 5 ventral. Second operations were carried out on the 15th or 20th postoperative days.Despite the disadvantages of being an interpolation flap which requires a second session and good patient cooperation, tongue flap is a choice for reconstruction of intraoral defects with its highly vascular structure, good mobility, localization, texture match, and low donor area morbidity.

Management of pulse oximeter probe-induced finger injuries in children: report of two consecutive cases and review of the literature.

Pulse oximetry is a standard noninvasive procedure for monitoring arterial oxygen saturation. Finger injuries related to pulse oximeter use have been reported as chemical or thermal burns, sun-tanning, pressure erosion, sensory loss, and gangrene. The mechanisms of these complications have not been definitively explained; but pressure ischemia, prolonged use, overheating of the probe, inappropriate use of the probe, and short circuiting are considered to be the main factors. We describe 2 cases of pulse oximeter probe-induced finger injuries, propose the possible mechanisms and factors related to the injury, and discuss the management.

Excised abdominoplasty material as a systematic plastic surgical training model.

Achieving a level of technical skill and confidence in surgical operations is the main goal of plastic surgical training. Operating rooms were accepted as the practical teaching venues of the traditional apprenticeship model. However, increased patient population, time, and ethical and legal considerations made preoperation room practical work a must for plastic surgical training. There are several plastic surgical teaching models and simulators which are very useful in preoperation room practical training and the evaluation of plastic surgery residents. The full thickness skin with its vascular network excised in abdominoplasty procedures is an easily obtainable real human tissue which could be used as a training model in plastic surgery.

Treatment of a congenital melanocytic nevus on the forehead with immediate tissue expansion technique: a three-year follow-up.

The aim of this case report was to determine the method and basic principles of immediate tissue expansion using a Foley catheter in the forehead region for treating a medium-sized congenital melanocytic nevus. A 4-year-old child presented with a supraorbitally located forehead congenital melanocytic nevus, close to the midline. Total excision and reconstruction with intraoperatively expanded forehead skin below the hairline was performed. Intraoperative tissue expansion using a Foley catheter allowed us to obtain expanded and enhanced local tissue, which had tissue characteristics similar to those of the forehead skin, and thus closure of a medium-sized defect without distorting important anatomic structures such as the brow and frontal hairline was possible. Of the two methods of tissue expansion, immediate expansion using a Foley catheter is a good alternative in single-stage reconstruction of head and neck defects because it has the advantage of omnidirectional expansion.

Effects of reduction mammoplasty on metabolic profile and body weight.

BACKGROUND: Advanced studies on adipose tissue have established that subcutaneous adipose tissue acts as an endocrine organ to help maintain homeostasis. Based on this information, many plastic surgeons have evaluated the metabolic effects of liposuction because liposuction is the most common surgical procedure in plastic surgery. Liposuction removes a substantial amount of subcutaneous fat from a specific area of the body. Mammoplasty is another procedure that removes a large amount of subcutaneous fat. In this study, the metabolic effects of reduction mammoplasty were evaluated with hemogram, blood glucose, lipid profile, insulin, and insulin resistance tests before and after surgery. METHODS: The study involved 35 patients who underwent reduction mammoplasty between January 2006 and June 2009. All the patients were evaluated with physical examination and their history, height, and weight were obtained. Venous blood samples were collected before, 4 h after, and 3 months after the surgical procedure to evaluate hemogram, blood glucose, insulin, and lipid profiles. The HOMA scores of the patients were calculated. Inferiorly based dermal pedicle, central pedicle, and free nipple graft techniques were used in the operations and all excision materials were sent for histopathological examination. RESULTS: The mean age of the patients was 39.6 ± 11.6 years. The mean excision volume was 2249 ± 1001 g. Body mass indexes were not significantly different before and 3 months after the surgery (p > 0.05). Blood glucose, LDL, HDL, triglyceride, total cholesterol, hemoglobin, and hematocrit values before and 4 h after the surgery were also different (p < 0.05). However, comparisons with the 3-month postoperative test results revealed no statistically significant differences (p > 0.05) and comparisons of all the measurements showed that insulin levels and HOMA scores were not significantly different (p > 0.05). CONCLUSION: The results of the present study showed that reduction mammoplasty operations do not have any positive effects on blood insulin, glucose profile, lipid profile, and body mass index 3 months after the surgery.