Aging of the skin in pseudoexfoliation syndrome.

BACKGROUND: It was reported that pseudoexfoliative material deteriorates iris, brain, heart and lung functions. This material is also found in the skin. AIMS: The purpose of this study was to investigate the possible effects of pseudoexfoliation material on the aging of the facial skin. STUDY DESIGN: Cross-sectional study. METHODS: Forty pseudoexfoliation syndrome (PES) cases and 40 age- and gender-matched controls were evaluated. Job, cigarette use and the presence of any systemic diseases as well as the duration of sun exposure for all the cases were recorded. All of the cases underwent facial skin examination with Wrinkle Assessment Scale as per Lemperle G et al. and Pinch Test. RESULTS: Wrinkle Assessment Scale scores of the groups also were compared for all 8 facial locations. There were statistically significant differences found between Wrinkle Assessment Scale scores in PES and Control Group for all 8 locations. Mean Wrinkle Assessment Scale scores of women were 4.12 ± 0.74 in Control Group and 4.75 ± 0.37 in PES group (p = 0.0001). For men, mean Wrinkle Assessment Scale scores were 3.77 ± 0.72 in Control group and 4.54 ± 0.36 in PES group (p = 0.002). CONCLUSION: These results implies that there is quicker progression in aging of facial skin in PES than normals.

Total and near-total lower eyelid reconstruction with prefabricated orbicularis oculi musculocutaneous island flap.

Full thickness lower lid defects are frequently encountered during daily practice. The unique anatomy of the eyelids hinders reconstructive efforts. The aim of the study is to develop an effective and easy procedure for the reconstruction of full thickness defects of the lower eyelid. Here we present six cases, which we treated with an orbicularis oculi musculocutaneous island flap prefabricated with a chondrocutaneous graft. Five of the six cases suffered from tumors, while one had congenital coloboma of the lower lid. A chondrocutaneous graft harvested from the ear was placed under the orbicularis oculi musculocutaneous flap. Three weeks later, the defect was created and the prefabricated flap was transposed to the defect. Two cases had superficial distal skin loss and one had prolonged oedema. No major complication or tumor recurrence was seen. Using this method, the principle "replace with like" is fulfilled. Orbicularis oculi musculocutaneous island flap prefabricated with postauricular chondrocutaneous composite graft seems to be a feasible method for the reconstruction of full thickness defects of the lower eyelid with its low donor morbidity and good outcomes.

A New Method to Harvest the Sural Nerve Graft.

OBJECTIVE: In this study, we developed a novel technique to harvest the sural nerve using the mini incisions and the carpal tunnel dilators. MATERIALS AND METHODS: The technique was applied to the 29 sides on 27 patients (24 men and 3 women). The mean age was 27.1 years (range 9-51). The diagnoses were soft tissue traumas in 23 cases, fracture in 2 cases, and previous complicated operation in 2 cases. The harmful effects of harvest procedure on the sural nerve graft were assessed double-blind histopathologically and compared with control group. RESULTS: All the nerve grafts were successfully harvested with no macroscopic damage to the sural nerve graft. There was no statistically significant difference between the histopathologic scores of the distal and proximal nerve segments (p>0.05). The average follow-up time was 17 months (range 8-46). In the postoperative period, no complication such as massive bleeding/hematoma, wound infection, skin necrosis, painful neuroma formation, or prolonged calf tenderness was observed. In all cases, there were inconspicuous scars. CONCLUSION: The method seems safe and has no damage on the nerve graft histopathologically. We believe that this technique may be used in future.

Comparison of tandir burns and other flame burns.

BACKGROUND: Because internal temperature of tandir may reach up very high levels, tandir burns, which is one of flame burns, may cause more morbidity and mortality than those of other flame burns. Therefore, we aimed to compare tandir burns with other flame burns in the present study. METHODS: In this study, we compared tandir burns with other flame burns concerning age, gender, total burn surface area, burn depth, hospitalization times, hospitalization duration, surgical procedures performed, wound culture results, burn localization and mortality. RESULTS: Tandir burn patients were treated in the hospital for an average of 27.6±9.5 days, while non-tandir burn patients were treated for a period of 16.5±12.5 days. A significant difference was found between the hospitalization periods of the two groups (p<0.001). Tandir burn, which is a type of flame burn, affects the women and children much more frequently than other flame burns (p=0.0001), causes deeper burns (p=0.0001), which requires more surgical intervention (p=0.0001) and causes more frequent wound site infection. CONCLUSION: We think that it would be beneficial to treat high-temperature burns, such as tandir burns, as a separate group from other flame burns. We believe that further studies to be conducted in this field will bring new approaches to the treatment of tandir burns.

Reconstruction of postburn contractures due to tandir oven.

The aim of the study was to evaluate postburn contracture reconstructions caused by high temperature such as tandir. The records of our 58 patients who were operated for burn contracture between 2008 and 2018 were retrospectively reviewed. Duration elapsed after the burn, localization of contracture, surgery applied, and the recurrence rates were recorded. McCauley classification was used to evaluate the severity of hand contractures. One hundred and thirty-seven contracture release operations were performed in 45 hands in 40 cases. Five patients had bilateral hand contractures. One hundred and sixty-three (84.9%) surgeries out of total 192 contracture release surgery were applied to the hand and foot region. FTSG alone was the most common method of treatment. Z-plasty was used the most frequently by our team as the flap surgery. Tissue damage is more severe due to very high temperature of the tandir and as a result, more frequent and heavier burn contracture occurs on hands and feet than other burn etiologies develops, and reconstructive operations are needed more frequently.

Reconstruction of complex shallow defects of the extremities with free serratus musculofascial flap

Background/aim: Thin and flexible flaps are needed for the repair of extremity tissue defects. Serratus fascia flaps are the most suitable options. There are only a few case reports and case series in the literature. We have aimed to increase the success rate by taking the serratus fascia flaps together with some muscle tissue for the repair of extremity tissue defects. Materials and methods: Between 2006 and 2015, 12 free serratus musculofascial flaps (FSMFFs) were transferred to 11 patients (8 males, 3 females) who had tissue shallow defects of the extremities due to different etiologic factors. The mean age was 24.6 years. Hospital records and patient photographs were reviewed and age, sex, etiologic cause, follow-up period, complication, flap success, cosmetic appearance, and functional results of the extremity were examined. Results: The mean follow-up period was 29.5 months (7­109 months). All of the flaps survived fully and no partial or full necrosis was observed. Partial graft loss was encountered in one patient and it was recovered secondarily with wound dressing. A major deficiency was not experienced postoperatively in the functions and movements of the extremities retained. The cosmetic appearance of the operation area was acceptable or fine. The donor areas healed in all the patients without any problems, and the scars were hidden and inconspicuous. Conclusion: In reconstruction of complex shallow defects of the extremities in which a gliding effect is desired, FSMFF may be an ideal option with its advantages as it does not sacrifice a major vessel, does not leave a hidden and short scar, can be harvested in wide dimensions, and allows the use of the surrounding tissues such as the latissimus dorsi muscle and scapular bone.

Preemptive Analgesic Efficacy of the Ultrasound-Guided Bilateral Superficial Serratus Plane Block on Postoperative Pain in Breast Reduction Surgery: A Prospective Randomized Controlled Study.

PURPOSE: Breast surgery is an exceedingly common procedure and associated with an increased incidence of acute and chronic pain. Preemptive regional anesthesia techniques may improve postoperative analgesia for patients undergoing breast surgery. The aim of this study was to evaluate the effect of preoperative bilateral serratus plane block on postoperative opioid consumption in patients undergoing breast reduction surgery. METHODS: After ethical board approval, 40 patients undergoing breast reduction surgery were randomized into 2 groups: control group (Group C, n = 20) and serratus plane block group (Group SPB, n = 20). Group C received bilateral ultrasound-guided 2 ml 0.9% saline subcutaneously each block side, Group SPB received ultrasound-guided bilateral SPB with 0.25% bupivacaine 30 ml each side. The groups were administered the routine general anesthesia protocol. All operations were performed with the mediocentral pedicled reduction mammaplasty technique by the same surgeon. Postoperative analgesia was performed intravenously in the 2 groups twice a day with dexketoprofen trometamol 50 mg and patient-controlled analgesia with fentanyl. Postoperative analgesia was evaluated using the visual analog scale (VAS). Fentanyl consumption, additional analgesia requirement and opioid-related side effects were recorded during the first 24 h after surgery. RESULTS: Compared with control, the VAS score was statistically lower in the SPB group during all measurement times (p < 0.05). The 24-h opioid consumption was significantly higher in the control group compared with the SPB group (372.50 ± 39.65 vs. 296.25 ± 58.08 µq, respectively; p < 0.001). In addition, the analgesia requirement was statistically lower in the SPB group (8/20 vs. 2/20, respectively, p < 0.028). Nausea or vomiting was observed more often in the control group than in SPB block (9/20 vs. 2/20, respectively, p = 0.013), whereas other side effects were similar for the two groups. CONCLUSIONS: SPB can be used safely bilaterally in the management of pain for breast reduction surgery as it is easy to perform, provides excellent analgesia, and reduces opioid consumption and opioid sparing effect. LEVEL OF EVIDENCE II: 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.

Versatile use of the posterior interosseous flap in the reconstruction of complex upper limb defects.

BACKGROUND: Reconstruction of the complex upper extremity defects is a challenging procedure for reconstructive surgeons because of the complex anatomical and functional structure of this region. In reconstruction, local and regional flap options involving the composite tissues are restricted. The posterior interosseous flap (PIO) has been presented 'in a single study' with a wide variety of uses, and in this study, the versatility of PIO has been tried to be emphasized by its multitude uses as well as its chance at adaptability to each case. Hence, due to this, the objective to highlight the versatile utility of the PIO flap in clinical practice and to present a good option for the reconstruction of complex upper limb defects for various cases have been targeted. METHODS: We used 26 PIO flaps in 25 patients (18 male and seven female patients) with upper limb defects. The main etiological causes were burn contracture, traffic accident, firearm and acute burn injury. Twenty-two flaps were harvested as fasciocutaneous and four flaps as osteo-fasciocutaneous manner, which were applied to the metacarpal defects. In this study, 25 flaps were transferred as pedicled flaps, of which 23 and 2 flaps had reverse and antegrade blood flows, respectively, whereas one flap was used as a free flap. RESULTS: The mean follow-up period was 14 months. All flaps except one, which had partial necrosis and secondary healed, survived completely. All patients were able to gain basic functions for daily routine activities in the late postoperative period. Patients and/or their parents were satisfied with the postoperative functional and aesthetic improvements. CONCLUSION: Many advantages of the PIO flap make it useful for the reconstruction of upper limb complex defects. It can be versatilely used based on changing its flow direction and enrichment of contents.

Novel Surgical Technique for Repair of Zygomatic Fractures: Lever Technique.

BACKGROUND: Zygoma is a very crucial component for the anteroposterior positioning of the midface and for the maintenance of facial contours. Zygomatic fractures are considered as the second most common type of facial fractures following nasal fractures. We have developed a new reduction technique called "lever," which is based on the application of lifting force as an alternative to the methods in which the pulling force is applied. PATIENTS: Over a 12-year period, 90 patients were treated with minimal access approach and 130 patients were treated with open reduction internal fixation (ORIF), using the lever technique. RESULTS: In the follow-up period, no complications occurred in any of the patients who underwent minimal access approach. Miniplate removal operation was performed in 3 of the patients. Enophthalmos developed in one patient. Since 4 of the 7 suboptimal reduction patients did not experience any functional or cosmetic problems, no treatment was necessary and the remaining 3 patients underwent fat graft due to the presence of malar depression. CONCLUSION: This minimally invasive surgical procedure we have developed can be successfully used both in the minimal access approach and in ORIF, especially in delayed cases. We recommend this method due to the reasons that it is safe to conduct, easy to learn, fast to apply, simple to perform, and also economical to deploy.

HISTORIQUE: L'os zygomatique est décisif pour le positionnement antéropostérieur de la partie médiane du visage et la préservation des contours du visage. Les fractures zygomatiques sont considérées comme la deuxième cause de fractures du visage en importance, après les fractures du nez. Les auteurs ont créé une nouvelle technique de réduction, la « technique de levier ¼, qui repose sur l'application d'une force de soulèvement plutôt que sur les méthodes reliées à une force de tension. PATIENTS: Sur une période de 12 ans, 90 patients ont subi un abord d'accès minime et 130, une fixation interne par réduction chirurgicale (FIRC) à l'aide de la technique de levier. RÉSULTATS: Pendant la période de suivi, aucun patient ayant subi l'abord d'accès minime n'a souffert de complications. Trois ont dû faire extraire des mini-plaques. Un patient a souffert d'énophtalmie. Puisque quatre des sept patients ayant subi une réduction sous-optimale ne présentaient aucun problème fonctionnel ou esthétique, ils n'ont pas eu besoin de traitement supplémentaire, et les trois autres ont reçu une greffe de tissus adipeux en raison d'un enfoncement malaire. CONCLUSION: Cette intervention peu effractive mise au point par les auteurs peut être utilisée avec succès pour l'abord d'accès minime et la FIRC, surtout dans les cas différés. Ils recommandent cette méthode parce qu'elle est sécuritaire, facile à apprendre, facile à appliquer et à exécuter et peu coûteuse.

Experiences with a modified preauricular mini incision with subdermally dissection in condylar and subcondylar fractures of the mandible.

OBJECTIVE: Condylar and subcondylar fractures (CSFs) are among the most common mandible fractures. If reduction of these fractures is not carried out correctly, serious complications can result, including infection, damage to temporomandibular joint (TMJ) function, malocclusion, nonunion, malunion, and ankylosis of the TMJ. METHODS: We used a preauricular, mini-incision, open technique (PMIOT) for CSF of the mandible. 66 patients (48 males, 18 females), with a total of 72 CSFs of the mandible, were repaired with PMIOT between 2011 and 2016. Average age was 37.8 years (range: 8-78). CSFs were located on the right side, left side, and bilaterally in 21, 27 and six patients, respectively. We used only one mini incision of length 2 cm for non-displaced subcondylar fractures. However, we had to perform a second mini incision for condylar fractures displaced by more than 45°, where subcondylar fractures overlapped, or where there was deep surgical exposure and difficulty with reduction. RESULTS: No early complications, such as bleeding, hematoma, seroma, infection, or parotid fistula, were seen in any patients. Temporary facial nerve paresis was reported in three patients, but these recovered spontaneously with conservative treatment within 15 days. Permanent facial nerve paralysis occurred in none of the patients. CONCLUSION: We believe that PMIOT is an effective, reliable, and feasible method for repair of CSF. It does not need any expensive and sophisticated tools, and has low complication rates. The mini incision used in our technique results in both a hidden scar and protection of essential structures in the region.

Total Lower Lip Reconstruction With Functional Gracilis Free Muscle Flap.

Free flaps based on static slings principles cannot provide esthetic and functional outcomes at a desired level in total or close to total lip loss. Therefore, dynamic methods have become a current issue in recent years and especially the idea of functional gracilis free muscle flap has been suggested. In this study, we present a case of a successful total lower lip repair with this flap.In a 78-year-old female patient who was diagnosed with squamous cell carcinoma involving the entire lower lip, bilateral modified radical neck dissection and full-thickness total resection with 1 cm surgical margin so as to include both commissures of the tumor were performed and then a free gracilis muscle flap was transferred from the same side. After microvascular anastomoses, the motor nerve of the flap was coapted to the marginal mandibular branch of the fascial nerve. The entire intra- and extraoral surfaces of the flap were covered with a partial-thickness skin graft which was taken from the right thigh. There was no any intra- or early postoperative complication. The skin graft and flap survived without any problem.In the controls of the patient who was followed-up for 8 postoperative months, it was observed that the gracilis muscle flap was well-adapted to its place, gained a very good tonus, its volume reduced over time and reached to ideal dimensions, and the overlying skin graft provided a good color and texture match with the surrounding tissues. The motor activity of the muscle was monitored with the Tinel's test. The speech and facial expressions of the patient were very clear. Despite the patient has an edentulous mandible and was not using prosthesis, her feeding with fluid and solid foods was free of problems, oral competence was highly sufficient, and there was no any drooling. Esthetic appearance was very good and intraoral vestibular depth was sufficient. The mouth opening was 3 cm. When comparing with upper orbicularis oculi muscle on the electroneuromyography (ENMG) ordered at the 8th month, a similar nerve conduction time (3.3 versus 3.8 ms) and contraction amplitude (0.5 versus 0.4 mV) values were obtained from the gracilis muscle. Follow-up of the patient is still continued with no tumor recurrence observed during this period.Being the real dynamic flap and its tonus of the functional gracillis free muscle flap in opposite to the static methods provides a significant superiority over the other options in terms of oral functions; moreover, the overlying skin graft presents a very good color and texture harmony aesthetically. This method is a candidate to be an exclusive surgical technique in the repair of total or close to total lip losses in the future.

The Temporal Artery Island Flap: A Good Reconstructive Option for Small to Medium-Sized Facial Defects.

PURPOSE: The reconstruction of facial defects is esthetically vital because of the unique skin color and texture of the face. The aim of this study was to show the utility of different temporal artery island flap designs for the reconstruction of upper and middle facial defects without contrast to the color and texture of the face. MATERIALS AND METHODS: This study is a retrospective case series conducted from November 2004 through May 2015. Patients older than 18 years with upper and middle facial defects smaller than 5 cm were included. RESULTS: The temporal artery island flap was used in 34 patients (21 men and 13 women). The etiologies were skin tumor in 17 patients, trauma in 10 patients, and burns in 7 patients. Major defect localization was in the temporal area in 12 patients, followed by the ear in 9 patients, the cheek in 6 patients, the eyebrow in 4 patients, and the nose in 3 patients. Flap designs consisted of the antegrade-flow island flap, the V-Y flap, and reverse-flow island flap in 23, 7, and 4 patients, respectively. All flaps survived completely except for 1 partial flap necrosis. Scars in the donor areas were inconspicuous. Patients' median age was 47.5 years (quartiles, 40.75 to 54), 61.8% were men, and median duration of follow-up was 11 months (range, 6 to 18 months). CONCLUSIONS: The temporal artery island flap could be a good option for the closure of minor to medium-size defects of the upper and middle face because of its good color and texture match, constant and reliable pedicle, wide pivotal movement, low donor site morbidity, and reverse-flow pattern.

Management of Saddle Nose Deformity Using Dermal Fat and Costal Cartilage "Sandwich" Graft: A Problem-Oriented Approach and Anthropometric Evaluation.

PURPOSE: In the surgical treatment of saddle nose deformity (SND), costal cartilage is often used. However, it can result in some potential complications such as resorption, bending, displacement, and its appearance under the skin (silhouette deformity). We prepared a composite "sandwich" graft by camouflaging the costal cartilage underneath the dermal fat graft as a novel method and applied it on SNDs using the closed rhinoplasty technique to prevent or minimize these risks. MATERIALS AND METHODS: The method was used for 21 patients (12 males and 9 females). Six anthropometric measurements, including the nasal dorsum projection, nasal supratip projection, nasal tip projection, nose length, labiocolumellar angle, and nasofrontal angle, were taken using the ImageJ program (National Institutes of Health, Bethesda, MD) on preoperative and postoperative lateral photographs. The data were compared statistically. RESULTS: The mean follow-up time was 29.95 months. No donor site complications developed. The sandwich grafts transferred to the nose were well tolerated in all patients. A partial graft failure and a mild bending, which were treated conservatively without supplemental surgery, developed in 1 patient each. No resorption, migration, bending, or appearance under the skin of the sandwich grafts were seen in the remaining patients. A statistically significant difference was found in all anthropometric measurements from the preoperative and postoperative groups except for 2. CONCLUSIONS: The severity of the deformity should be exactly determined before surgery, and cartilage grafts should be used accordingly for successful repair of SND. The sandwich technique, as a practical, effective, and long-lasting treatment method, could minimize the potential complications and risks of revision.

Treatment of Linear Scleroderma (en Coup de Sabre) With Dermal Fat Grafting.

BACKGROUND: Linear scleroderma, also known as "en coup de sabre," is a subtype of localized scleroderma that warrants aesthetic correction because it appears on the forehead region in children. OBJECTIVE: To report dermal fat grafting as a novel and effective surgical treatment option in linear scleroderma. METHODS: Under local anesthesia, a dermal fat graft was successfully placed into a subcutaneous pocket that was prepared underneath the depressed scar. The donor site was closed primarily. RESULTS: No early or late complications developed postoperatively. After 1-year follow-up, the dermal fat graft was viable, the depressed scar was adequately augmented, and a good aesthetic result and patient satisfaction were obtained. CONCLUSION: We believe that dermal fat grafting is a cost-effective option and provides a long-lasting aesthetic outcome in the management of linear scleroderma.

Reconstruction of the Wide Scalp Defects Using Free Latissimus Dorsi Flap Assisted With Arteriovenous Loop.

Reconstructions of the wide scalp defects are still a challenging task because of the accompanied recipient vessel issues. Arteriovenous loop (AVL) grafts are a suitable vascular conduit that can be used to support free tissue transfer, when adjacent blood supply is inadequate. We report 2 patients of successful wide scalp reconstruction, using a free latissimus dorsi (LD) flap assisted with AVL. Both flaps and AVL grafts fully survived postoperatively. No complications related to the recipient and donor areas developed. The flaps obtained a durable barrier and an acceptable aesthetic appearance. We believe that AVL can be a useful adjunct for increasing the success rate of wide scalp reconstructions with inadequate adjacent arterial inflow or venous outflow. The free LD flap is a good option with its wide surface, rich vascularity and relatively low donor morbidity in such reconstructions.

Neurotized sural flap: An alternative in sensory reconstruction of the foot and ankle defects.

INTRODUCTION: The sensory reconstruction of the lower extremity is one of the main goals in lower extremity reconstruction. Reconstructive options endowing sensory recovery are limited. The aim of this report is to evaluate the neurotized sural flap in reconstruction of foot and ankle defects. PATIENTS AND METHODS: Seven cases that were operated for foot and ankle skin defects with the neurotized sural flap were reported. The largest flap was 10 cm × 14 cm in size. Median age was 38 years. Four defects were on the heel, two were on the ankle, and one was on the dorsum of the foot. The sural nerve was coaptated to a recipient nerve in seven patients. RESULTS: All flaps survived totally. Follow-up time ranged between 9 and 29 months. All cases had hot-cold perception and two-point discrimination at average 14 ± 1.63 mm at 6th month. Sensory conduction test revealed very low action potentials related to stimulation of the flap. CONCLUSION: The neurotized sural flap is a versatile modification, for the sensory reconstruction of the moderate size foot and ankle defects.

Total lower lip reconstruction using free neurotendinofasciocutaneous anterolateral thigh composite flap: a case report.

Total lower lip reconstructions are challenging procedures because of poor aesthetic and functional outcomes and limited availability of donor tissues that anatomically imitate the lip. We hereby report the free neurotendinofasciocutaneous anterolateral thigh composite flap as a new reconstructive option. A 48-year-old man presenting with a squamous cell carcinoma of the lower lip underwent wide resection of tumor, bilateral neck dissection, and lower lip reconstruction with the mentioned flap where the lateral femoral cutaneous nerve and tensor fascia lata tendon were included. No complication was encountered postoperatively. The flap survived totally. Understandable speech, oral competence, and uneventful nutrition were obtained. Furthermore, tactile, pain and heat sensations, and two-point discrimination of 12 mm at the flap were regained. In reconstruction of the lower lip, this flap was first described in the literature and can be a good candidate as a reconstructive option.

Latissimus dorsi flap harvest with a short incision.

Latissimus dorsi (LD) flap is one of the most common options utilized in reconstructive armamentarium. In this report, we present our experience on harvest of the full LD muscle flap through a short incision. Twelve free and two pedicled full LD muscle flaps were raised in 14 patients (9 males and 5 females). In this technique, an oblique incision was placed 5-7 cm caudal to axillary apex, beginning from the posterior axillary line, so as to center the neurovascular hilus. The length of incision was 10 cm in adults and 8 cm in children. Mean dissection time was 45 min. All flaps survived totally. Seroma formation developed in two cases and treated with syringe aspiration and compressive dressing. In late postoperative period, donor site scars became inconspicuous and patient satisfaction was high. Short incision technique may be a good option to overcome scar problems in donor site of the LD flap. The technique reduces the dissection time and does not require sophisticated surgical devices and skill, when compared to endoscopic LD flap harvesting from the literature.