Total Scalp Replantation: Surgical Tricks and Pitfalls.

BACKGROUND: Two patients were successfully operated on for total scalp avulsions. METHODS: Ages were between 11 and 35 years, and both patients were female. Bilateral temporal artery and veins were used as the recipient pedicles. Interpositional vein graft harvested from the left forearm was used in 1 patient. No nerve repair was performed. RESULTS: The scalp was successfully replanted in both cases. Venous congestion and arterial insufficiency were observed in 1 patient. Successful revision of the vascular anastomosis was performed. Total necrosis of the upper helical rim was observed in 1 patient. A mean size of 3 × 3 cm of tissue necrosis was observed in the occipital region of all patients. One patient was treated with split-thickness skin grafting, whereas the other one was left for secondary healing. CONCLUSIONS: The "replace like tissue with like tissue" represents the philosophy in replantation surgery. Although reconstructive surgeries imply advanced surgical methods, scalp replantation remains the only ideal surgical modality to create an embellishing natural-looking hair-bearing scalp. In this article, we present some tricks and pitfalls of total avulsed scalp replantation as well as our skills and literature review.

The use of titanium clips in septal surgery for correction and strengthening.

Permanent correction of septal deformities is one of the most difficult and controversial subjects in aesthetic nasal surgery. The main reasons for failure in most of the corrective procedures are either not to weaken the septal cartilage enough to straighten it, or to treat the septum too radically causing iatrogenic deformities or predisposing it to new deformities postoperatively. Our approach to correct septal deformities relies on the principle of strengthening/reinforcing the septal cartilage (with or without some weakening maneuvers to correct the deformities beforehand) with application of titanium hemoclips at some critical locations in septum. Eighty-seven patients operated on between 2007 and 2009 are included in this study. Thirty-six of these patients had combined septo-nasal deformities while the remaining 51 had solely septal deformities. In 30 patients with septo-nasal deformity the technique was proven to be successful. The remaining 6 patients of this group had axial nasal deformity (rather than intrinsic septal problems) and did not respond to our technique successfully. Within four years of follow up, we did not encounter any recurrences, infections, ulcerations or exposure in the mucosa covering the titanium clips. None of the titanium clips were required to be removed for any reasons.

Comparison of clinical outcomes between single- and multiple-perforator-based free thoracodorsal artery perforator flaps: clinical experience in 87 patients.

BACKGROUND: Although thoracodorsal artery perforator flaps have not gained popularity in the reconstructive era, the results of recent studies regarding the vascularity of thoracodorsal artery perforator flaps are promising. In the present study, the authors aimed to determine the clinical outcomes of free multiple-perforator versus single-perforator thoracodorsal artery perforator flaps. METHODS: Eighty-seven patients with various defects underwent reconstruction with free thoracodorsal artery perforator flaps. The flap was used for upper extremity reconstruction in 43 patients (49.4 percent), for head and neck reconstruction in 16 patients (18.4 percent), and for lower extremity reconstruction in 28 patients (32.2 percent). Of the 87 flaps, 48 (55.2 percent) were based on a single perforator, whereas 39 flaps (44.8 percent) were based on multiple perforators. The single- and multiple-perforator-based thoracodorsal artery perforator flaps were compared regarding clinical outcomes and morbidity. RESULTS: The morbidity rate was found to be significantly higher in the single-perforator-based group. Of the patients in the single-perforator group, seven patients had transient venous congestion, five were heparinized and treated with leeches for permanent venous congestion, six had partial necrosis, and one had total necrosis. In the multiple-perforator-based group, two patients had transient venous congestion, and no partial or total necrosis was observed. CONCLUSION: Despite the fact that dominant perforators may often be absent, this study showed that a multiple-perforator-based thoracodorsal artery perforator flap may be more reliable with safe vascularity compared with a single-perforator-based flap.

The bipedicled latissimus dorsi myocutaneous free flap: clinical experience with 53 patients.

The Latissimus dorsi musculocutaneous flap is a valuable workhorse of the microsurgeon, especially in closing large body defects. One of the pitfalls in harvesting the flap, is particularly in its inferior aspect which may be unreliable. Here we report a series of 53 patients who were undergone bipedicled free latissimus dorsi musculocutaneous free flaps for extensive tissue defects. The age of patients were between 5 and 64 and all of them were males. The wound sizes in these patients ranged between 31-35 x 10-12 cm and flap dimensions were between 38-48 x 6-8 cm. Perforator branches of the 10th intercostal vessels were dissected and supercharged to the flaps to reduce the risk of ischemia of the inferior cutaneous extensions. The secondary pedicles were anastomosed to recipient vessels other than the primary pedicles. Recipient areas were consisted of lower extremities. Four patients suffered of early arterial failure in the major pedicle and all revisions were successfully attempted. Neither sign of venous congestion nor arterial insufficiency were observed at the inferior cutaneous extensions of the flaps, and all defects were reconstructed successfully. All donor sites were primarily closed, only two patients suffered from a minor area of superficial epidermal loss at the donor site, without suffering any adjunct complications. In conclusion coverage of large defects can be safely performed with extending the skin paddle of latissimus dorsi flap as a bipedicled free flap.

Bilateral ductal carcinoma in situ of the breast after radiation therapy for Ewing's sarcoma of the vertebra in a young woman: report of a case.

Thoracic radiation in the early years of life is a known risk factor for breast cancer later in life. A 21-year-old woman who had received thoracic radiation therapy for Ewing's sarcoma of the vertebra 9 years earlier was referred to our hospital for investigation of a palpable mass in her left breast. Ultrasonography and excisional biopsy showed ductal carcinoma in situ (DCIS) of the left breast, with no detectable pathology in the right breast except that it was more hypoplastic than the left breast. Considering the known risk factors for invasive breast cancer in both breasts, we performed bilateral skin-sparing mastectomy with immediate breast reconstruction using subpectoral implants. The final histopathological diagnosis was bilateral DCIS.

Blood loss and transfusion rates during repair of craniofacial deformities.

Surgical procedures for correction of craniofacial deformities resulted in unavoidable and extensive blood loss in small children and infants. Almost all of the patients undergoing these procedures will undergo a blood transfusion either during or immediately after the operation. A retrospective review of 30 patients who underwent craniofacial surgery was performed in this study to determine the magnitude of transfusion required for craniofacial surgery, document transfusion morbidity, and identify variables associated with the transfusion. The mean estimated blood loss was 566.8 mL, the mean intraoperative transfusion was 394.8 mL, the mean postoperative transfusion was 103.2 mL, and the mean total transfusion was 505 mL. The mean operative time was 450 minutes, the mean preoperative hemoglobin and the mean postoperative hemoglobin before hospital discharge were 11.6 g/dL and 10.3 g/dL, respectively. Craniofacial surgical procedures involve extensive scalp dissection and calvarial and facial bone osteotomies in patients with a low total blood volume. Every medical and surgical strategy for minimizing the need for blood transfusion should be considered.

Effects of growth factors on doxorubicin-induced skin necrosis: documentation of histomorphological alterations and early treatment by GM-CSF and G-CSF.

Extravasation of vesicant antineoplastic agents such as doxorubicin into the skin or subcutaneous tissues may result in loss of the full thickness of the skin or underlying structures. Several treatment methods have been advocated but none has demonstrated any superiority to the others. The authors designed a controlled animal study in 88 rats to test three methods of early treatment of extravasation of the vesicant antineoplastic agent doxorubicin. The first step of the study included 48 Sprague-Dawley rats. All animals received intradermal injections of 1 mg doxorubicin superficially to the panniculus carnosus in the dorsum. The rats were then divided into four groups of 12 rats each, as follows: group 1, no treatment; group 2, immediate intradermal injection of 0.1 ml saline to the same site; group 3, immediate intradermal injection of 10 microg granulocyte macrophage-colony stimulating factor (GM-CSF) in 0.1 ml saline to the same site; group 4, immediate intradermal injection of 10 microg granulocyte-colony stimulating factor (G-CSF) in 0.1 ml saline to the same site. During the next 6 weeks the rats were observed for the development of necrosis. Ulcers developed and reached maximum size two weeks after the injections. The largest ulcers according to area were observed in group 1 and the mean value was 21.25 mm (p < 0.05). Although wound areas were significantly smaller in the saline group than in the control group and the mean value was 7.58 mm (p < 0.05), the smallest lesions were observed in groups 3 and 4, and the mean values were 1.08 mm and 0.83 mm respectively (p < 0.05). There was statistically no difference with regard to mean ulcer area between groups 3 and 4. During the second step of the experiment, the remaining 40 Sprague-Dawley rats were used. Groups containing 10 rats each were designed similarly after all animals received intradermal injections of 1 mg doxorubicin into the back. On the 10th day after the injection, the entire area of the ulcer together with the underlying panniculus carnosus was excised for pathological examination and for determination of glucose 6-phosphate dehydrogenase (G6PD) activity. On microscopic examination, the extravasated ulcer consisted of a large area of ischemic necrosis. There was marked damage to small blood vessels in the form of fibrinoid necrosis and vasculitis. Injured vessel counts were higher in the control group (group 1; p < 0.05). No difference was observed in G6PD activity between the groups. The authors conclude that both saline and tissue growth factors (GM-CSF and G-CSF) are useful for the early treatment of doxorubicin extravasation; however, GM-CSF and G-CSF are more beneficial.