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.

Panniculectomy with bariatric surgery in super morbid obesity patients.

OBJECTIVE: Panniculitis is an inflammation of the subcutaneous fat common in patients defined as super-super obese (>60 kg/m2). Poor hygiene and skin infections are common in the super morbidly obese group due to impaired metabolism of subcutaneous fat tissue, especially at abdominal folding. In our study, we will discuss the short-term results of panniculitis that develops as a result of these, simultaneously with bariatric surgery. MATERIAL AND METHODS: In our study, six super morbid obese patients with Body Mass Index (BMI) of 80 kg/m2, 77 kg/m2, 74 kg/m2, 72 kg/m2, 68 kg/m2, 65 kg/m2, respectively, and sub umbilical skin tissue panniculitis were evaluated. These patients underwent bariatric surgery as a result of the obesity council decision. In the preoperative evaluation of the patients, it was observed that the blood supply to the subcutaneous fat tissues under the umbilicus was impaired, and the dermis/epidermis was hypertrophied. RESULTS: Mean BMI of patients 73 kg/m2. Sleeve Gastrectomy (SG) was performed in 4 patients, Mini Gastric Bypass (MGB) was performed in 1 patient, and modified transit bipartition was performed in 1 patient. Infected erythematous lesions were detected on the skin secondary to ischemia, especially in some areas. After the patients performed the operations, a panniculectomy of approximately 70x30x20 cm was performed from under the umbilicus to the transverse line and up to the fascia. CONCLUSION: Panniculectomy and bariatric surgery are recommended in the appropriate patient group. Extensive prospective studies are required to define further the burden of infectious morbidity and mortality conferred by obesity. KEY WORDS: Bariatric surgery, Obesity, Panniculectomy.

Application of the free-style brachial artery perforator based propellar flap in the management of axillary hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a chronic and recurrent inflammatory disease often requiring surgical intervention in extensive lesions. Total of seven axillary lesion with HS was treated with free-style perforator based propeller flaps (innominate perforator originating from the brachial artery) after complete excision. The flap design mimicked the axis and design of the brachioplasty surgery. The flaps were elevated and after obliterating the defect, the remnant flap was discarded and donor site was primarily closed. All flaps were performed successfully and HS did not recur in any of the patients. In addition, the operated limb also showed a reduction of arm circumference of more than 5 cm. This is the first report using the free-style perforator based propeller flap to reconstruct the axillary HS. It is a simple and a reliable approach yielding good functional and aesthetic outcome with additional advantages of providing a brachioplasty.

Treating surgical site infection following posterior instrumentation with free-style deepithelialized propeller flap: A case report.

Surgical site infection is a challenging situation for all types of surgeons. Extensive debridement with or without implant removal can create soft tissue defects. A well-vascularized, adequate soft tissue is needed to cover the wound and to fill the dead space for proper healing. Herein, we describe our approach to a large posterior trunk defect with dead space and our solution to manage an intraoperative complication using a free-style deepithelialized propeller flap.

Challenges of Setting up a Lower Extremity Reconstruction Practice in a Constrained Environment.

BACKGROUND: Microsurgical lower extremity reconstruction remains challenging, especially when resources are limited such as lack of proper equipment, human resources, administrative support, and located in a remote area far from tertiary care. Nevertheless, reconstructive solutions are required, especially when in urgent trauma situations. In this article, we evaluate ways of overcoming challenges and issues that should be considered in a newly established unit by sharing our initial lower extremity reconstruction experience. METHODS: We report a local hospital's initial lower extremity reconstruction experience in February 2017 to January 2018. Through a total of seven patients, we tried to enhance the environment, instruments, nurses' contribution, and perspective of the peers and community in terms of factors related to the surgeon, hardware, environment, supporting faculty, reimbursement, and patients. RESULTS: Four patients underwent reconstruction with a freestyle propeller flap and three with an anterolateral thigh flap; in one case, a superficial circumflex iliac artery perforator flap was chosen to salvage partial flap necrosis. Increased experience of the surgeon, new equipment, continuing nurse/patient education, and collaborating with other departments allowed us to choose more challenging flaps and be more meticulous while decreasing the operation time and hospital stay. CONCLUSION: To start a lower extremity reconstruction practice in a resource-poor environment, the surgeon needs to evaluate the relevant factors; moreover, he or she should continuously improve them until a working methodology is achieved. Despite all the challenges, the adaptations learned at this center can be applied to other local hospitals around the world to set up a lower extremity reconstruction practice and improve its outcomes.

Retrospective analysis of the first 50 emergency/elective surgical cases in terms of mortality and morbidity in CoVid-19 Pandemic Hospital in Istanbul.

2019-nCoV currently named SARS-CoV-2 is a highly pathogenic Coronavirus identified in Wuhan China in December 2019. Turkey declared the first case relatively late compared to Asian and European countries on March 11, as the first SARS-CoV-2 infection in Turkey. In this study, we aimed to determine patients' outcomes in 50 surgeries done in the incubation period of SARS-CoV-2 in our hospital. METHODS: We retrospectively analyzed the clinical data of 50 patients who underwent surgeries during the incubation period of CoVid-19 at Istinye University Gaziosmanpasa Medical Park Hospital in Istanbul, from March 2 to April 11, 2020. RESULTS: The age of 50 patients range was 21 to 73, and the median age was 43.32 (64%) patients were women. The median length of hospital stay is 2.6 days (1-21). Operations at various difficulty levels were also performed on patients with co-morbidities. No complication or mortality was observed except for 1 patient, and the ICU requirement of that patient was also due to high energy trauma. CONCLUSION: Although contrary claims have been made in various studies; it is the primary duty of us surgeons to operate CoVid-19 positive/suspicious patients safely and without any contamination, and on the other hand, to continue their operations without victimizing negative patients. In this pilot study, we would like to emphasize with necessary and adequate measures these can be achieved. KEY WORDS: CoVid-19, SARS-CoV-2, Surgery.

Free-style Deepithelialized Propeller Flaps: An Ideal Local Flap to Obliterate Wounds with Dead Space.

BACKGROUND: The reconstruction of the posterior trunk, especially with large dead spaces, remains challenging. Regional muscle flaps may lack adequate volume and reach. The purpose of this report was to evaluate the efficacy of deepithelialized free-style perforator-based propeller flaps to obliterate defects with large dead space. METHODS: A total of 7 patients with defects on the posterior trunk with large dead spaces were evaluated. After complete debridement or resection, all flaps were designed on a single perforator adjacent to the defect, deepithelialized, and then rotated in a propeller fashion. Flaps were further modified in some cases such as folding the flap after deepithelialization to increase bulk and to obliterate the dead space. RESULTS: The flap dimension ranged from 10 × 5 × 1 to 15 × 8 × 2.5 cm based on a single perforator. The rotation arch of the flap ranged from 90 to 180 degrees. Uneventful healing was noted in all cases. One case showed latent redness and swelling at 7 months after falling down, which resolved with medication. During the average follow-up of 28 months, there were no other flap and donor site complications. CONCLUSION: The deepithelialized propeller flap can be used efficiently to obliterate dead spaces in the posterior trunk and retains advantages such as having a good vascular supply, adequate bulk, sufficient reach without tension, and minimal donor site morbidity.

Management of soft tissue extremity degloving injuries with full-thickness grafts obtained from the avulsed flap.

BACKGROUND: A "degloving injury" is referred to as seperation of cutaneous tissue from the deeper structures of the body. Although many methods have been defined to reform the tissue integrity; defatting and readaptation of the avulsed flap still comprises one of the most effective methods. METHODS: From 2000-2012, we treated a total of nine patients with avulsed extremities with defatting and readaptation of the same flap. The fat compartment of the flaps was removed and the skin was meshed. The patients were followed-up with for an average of 12 months (range: 8-18 months). RESULTS: Total closure of the defect and healing was achieved in seven patients. Although 30% of the total surface area of the graft was lost in one patient, and 10% in another, total epithelialization was achieved later with secondary grafting. CONCLUSION: Defatting, meshing and readaptation of the same flap to its original site is still a valuable option for avulsion injuries because of the relative ease of the procedure, shorter operative times, and usability of the procedure by general surgeons. This technique might be particularly important in places where a reconstructive plastic surgeon is not available.

"Roller coaster maneuver via lateral orbital approach" for reduction of isolated zygomatic arch fractures.

Numerous techniques have been reported for the reduction of zygomatic arch fractures. In this article, we aimed to describe a technique we named as "roller coaster maneuver via lateral orbital approach" to closed reduction of the isolated-type zygomatic arch fractures. Surgical outcomes of 14 patients treated with this method were outlined.