Reconstruction of burn contractures with free anterolateral thigh flap in various anatomic sites.

BACKGROUND: Burn contractures that cause a restriction in extremity movements have to be reconstructed. Free microvascular flaps are generally needed in cases of severe contractures. The ideal free flap for severe contracture defects has to have a large skin island without bulk and a long pedicle for preventing recurrence and tension-free adaptation. Anterolateral thigh flap (ALT flap) that meets these features has widely been used for several indications in reconstructive surgery. Usage of ALT flap in burn contracture was described for burn and axillary contractures in literature. In this study, the usage of free ALT flaps in various anatomic contracture sites was reported. METHODS: Fifteen free ALT flaps were performed in 14 (12 male, two female) patients with a mean age of 36.6. Burn contracture defects in neck, axilla, popliteal, cubital region, plantar foot and hand were reconstructed with ALT flap. RESULTS: No total flap loss was encountered. Distal flap necrosis was seen in one case. All patients had significant improvement in a range of motions. Recurrence in contracture was seen in one patient with hand flexor contracture due to lack of physical treatment. CONCLUSION: ALT flap can safely be used in various anatomic contracture sites. Suprafascial elevation of the flap can be preferred for better adaptation in the neck, hand and foot and prevention of bulky appearance.

Double Layer Reconstruction of Exposed Cardiac Implantable Electronic Devices in Elderly Patients.

Background Elderly patients with multiple comorbidities may not be candidates for cardiac implanted electronic device (CIED) explantation in cases of exposition. Excision of all unhealthy and inflamed scar tissue results in a skin defect that must be covered. Small- to moderate-sized local skin flaps and subpectoral placement of CIEDs have been described in the literature. However, these techniques still could not eliminate the risk of recurrence. In terms of minimizing the recurrence risk, we aim to increase the flap dimensions for getting better circulation and tension-free closure after subpectoral placement. Material and methods Six patients who were operated for a dual-layer reconstruction of exposed cardiac implants between 2017 and 2020 were included in the study. All patients were referred to plastic surgery as soon as the wound biopsy culture results were negative after systemic and topical antibiotic treatment by cardiology department. Results No flap loss or wound dehiscence was seen with a mean duration of 11 months follow-up. Early hematoma was encountered in a patient who was managed with irrigation and drain renewal. One patient developed suture abscess in the second month postoperatively. Knots were removed and wound healed without further intervention. Conclusion Double layer closure of exposed cardiac implants with large breast fasciocutaneous flap after subpectoral placement of pulse generator and leads suggest durable and reliable coverage in elderly patients with multiple comorbidities.

A descriptive study of facial lacerations presenting to pediatric emergency in Turkey.

BACKGROUND: Soft tissue trauma of the face is considered a leading cause of presentation and referral to the pediatric emergency department. The present study aims to evaluate the demographics properties of facial injuries presenting to the pediatric emergency. METHODS: In this study, 1160 patients presented with a simple facial laceration to the pediatric emergency department of Baskent University were reviewed from 2011 to 2017. Patients up to 18 years of age were included. We evaluated demographics about patients' age, sex, the cause of injury, the location of laceration and timing of the injury. Age was categorized according to the National Institute of Child Health and Human Development (NICHD) pediatric terminology into five groups as follows: 0-12 months, 12 months-2 years, 2-5 year, 6-11 year, and 12-18 years. The following analyses were performed to each age group: a number of cases, male to female predominance, timing of injury (e.g., early morning, afternoon, evening, late evening and at night), the place that the injury has occurred (e.g., at home, at school, in sport hall), the cause of injury (fall, hitting a hard subject, sports-related), the location of laceration (forehead, periorbital area, cheek, perioral area, nose, submental area) and the incidence according to the season. RESULTS: Number and relative percentages of cases were as follows: 0-12 months (n=127, 10.9%), 12-24 months (n=113, 9.7%), 3-5 years (n=385, 33.1%), 6-11 years (n=403, 34.7%) and 12-17 years (n=132, 11.3%). The average age of children was 6.5 year (range, 5 month - 17.9 year). The age group 6-11 showed a higher incidence compared to other age groups (n=403, 34.7%). Fifty-three percent of the population was younger than six years and there was a male predominance in all age groups. CONCLUSION: The demographic data provided in this study can be useful in trauma prevention programs which are effective in reducing the incidence, nature and severity of facial lacerations. Parents should be reminded of age-specific preventive measures in injury avoidance.

Successful Replantation of Tamai Zone I Amputation with Delayed Vein Repair.

Digital vein repair is one of the most challenging phases of distal phalanx replantation. Digital veins at very distal levels have a small vessel caliber and collapsed lumens, which makes them hard to identify and handle. Digital veins may not be visible immediately after arterial anastomosis. In this scenario, the patient can be taken to the operative room several hours after revascularization to visualize dilated and expanded veins for late digital vein repair. Late digital vein repair is a reliable and alternative method to artery only replantation. In this report, a successful replantation with late digital vein repair in Tamai Zone I is presented.

Does methylene blue increases capsular contracture in immediate breast reconstruction with silicone implant? An experimental study.

Recently, most of the immediate breast reconstructions following mastectomy are being carried out with the use of silicone implants. In these patients, methylene blue is being used for the detection of sentinel lymph nodes. This experimental study was performed to determine the effect of methylene blue on capsular contracture around breast implants. Thirty-two Sprague Dawley rats were divided into 4 groups. Custom made silicone blocks were placed on the back of animals. In group 1, the incision was closed without performing any additional procedure. In group 2 (control), 0.1 mL of 0.9% normal saline was instilled into the pocket. Group 3 and 4 (study groups) received 0.1 and 0.2 mL of 1% methylene blue, respectively. On postoperative day 60, implants and capsular tissue were extracted. Capsule formation was evaluated both macroscopically and microscopically. The histological evaluation included capsule thickness, inflammation, neovascularization, and fibrosis gradients. Regarding capsule thickness, there were statistically significant differences between groups 1-3, 1-4, 2-3, and 2-4. Although there were more moderate and severe inflammation gradients in groups III and IV, there was no significant difference regarding inflammation severity between control and study groups. In respect of vascular proliferation, there was a statistically significant difference between control and study groups. Similarly, fibrosis gradients were higher in both groups 3 and 4. The study showed that the injection of methylene blue around silicone implants enhanced the formation of capsular contracture. In this case, the degree of contracture was independent of the dose given. Abbreviations: CC: capsular contracture; MM: methylene blue; SLNB: sentinel lymph node biopsy; NS: normal saline; H&E: hematoxylin and eosin; D: dorsal; V: ventral; L: lateral; n: frequency.

Escharotomy for the Face: Facial Aesthetic Subunit Principle-Based Approach.

Escharotomy is the relaxation of an eschar through longitudinal or horizontal incisions in order to protect regional perfusion. In peripheral areas, such as limbs, trunk, and neck, eschar pressure poses significant issues; it causes circulatory disorder in limbs and potential limb loss, inadequate thoracic expansion in the thorax, and perfusion and oxygenation problems in the neck. To prevent complications, a basic rule of burn surgery is to perform escharotomy incisions quickly and without hesitation. However, the face is not an area in which eschar formation is commonly seen due to its robust vascular supply and patients' protection reflex. Although descriptive drawings and guides for facial escharotomy have yet to be published, relaxation of axial arteries in terms of compression from eschar formation may be needed. Here, we present a case of escharotomy based on facial subunit principles.

The Effects of Adipose Derived Stromal Vascular Fraction and Platelet-Rich Plasma on Bone Healing of a Rat Model With Chronic Kidney Disease.

BACKGROUND: Chronic kidney disease (CKD) impairs osteoblast/osteoclast balance and damages bone structure with diminished mineralization and results in bone restoration disorders. In this study, we investigate the effects of adipose-derived stromal vascular fraction and platelet-rich plasma (PRP) on bone healing model in rats with CKD. METHODS: Sprague-Dawley rats were separated into 4 groups. All groups except group I (healthy control) had CKD surgery using 5/6 nephrectomy model. All groups had intramedullary pin fixation after receiving bone fracture using drilling tools. Group II rats were used as control group for CKD. Group III rats received PRP treatment on fracture site. Group IV rats received PRP and stromal vascular fraction treatment on fracture site.Weight loss and blood samples were followed at the time of kidney surgery, third, sixth, and 12th weeks. Bone healing and callus formations were compared, biomechanically, radiologically, histopathologically, and immunohistochemically. Osteoblastic transformation of stem cells was assessed with DiI staining. RESULTS: Negative effects of CKD on bone healing were reduced by increasing mechanical, histological, radiological, and biochemical properties of the bone with stromal vascular fraction and PRP treatments. Although thickness of callus tissue delayed bone healing process, it also enhanced biomechanical features and bone tissue organization. CONCLUSIONS: Platelet-rich plasma and adipose-derived stromal vascular fraction treatments were effective for bone healing in animal model, which can be promising for clinical trials.

Clinical Experiences with Closed Incisional Negative Pressure Wound Treatment on Various Anatomic Locations.

Background Closed incisional negative pressure wound treatment (ciNPWT) is one of the promising methods for the prevention of complications in surgical incisions. The mechanisms of ciNPWT have previously been elucidated and in this series, we demonstrate various, as of yet, underreported uses for the technology. Our aim is to share our experience with ciNPWT on various anatomic sites with novel indications.  Materials and methods ciNPWT was used in 24 patients. The mean age was 49.6. All the incisions were sutured, clean, and non-infected. Patients' sex, age, comorbidities, anatomic location of the wound, and the indications for ciNPWT were recorded. Results The mean number of applications was three per patient. One suture dehiscence after one session of ciNPWT was encountered in a flap donor site of an infant operated for meningomyelocele. Late-term seroma and hematoma formation were encountered in two patients. No surgical site infection, wound dehiscence, and ciNPWT related complications were seen in other patients. The majority of the applications were on the trunk, lower extremity, pelvis, upper extremity, and scalp respectively. Indications for ciNPWT utilization were preventing dehiscence, seroma, and hematoma formation in the majority of the patients. Conclusion ciNPWT is reliable and effective in the prevention of post-operative wound dehiscence and surgical site infections. It can be used safely in various locations and different indications for preventingcomplications such as preventing dehiscence in revision surgeries, cerebrospinal fluid (CSF) fistula formation in the scalp, and wound breakdown in chronic corticosteroid use.

Antioxidant and physicochemical properties of cookies containing raw and roasted hemp flour.

BACKGROUND: There has been a resurrection of interest in traditionally cultivated hemp seeds as an alternative food ingredient source over the last few years. Hemp seeds are an excellent food source in terms of protein, dietary fiber, omega fatty acids, vitamins and minerals. In this way,  hemp flour allows the development of  a product with a high nutritional content for human nutrition. METHODS: This study aimed to investigate the effects of using raw and roasted hemp flour instead of wheat flour (0-5-10-15-20%) in cookies in terms of physical, chemical and sensorial properties. RESULTS: The results showed significant differences (p < 0.05) in some chemical and physical properties among cookies. The addition of raw and roasted hemp flour significantly (p < 0.05) affected the color parameters of the cookie samples; L* and b* values decreased and a* values increased. The cookie formulation with increased hemp flour (raw or roasted) resulted in an increase in ash, protein, fat, total phenolic content and antioxidant activity values in the cookie samples, and the highest values were observed with a 20% level. The raw and roasted hemp flour content significantly decreased the hardness and resulted in softer cookies. For sensory evaluation, the cookies supplemented with raw hemp flour up to 20% and roasted hemp flour up to 15% were found to be more desirable by the panelists in terms of overall acceptability. CONCLUSIONS: The results showed the effects of the process applied to the seed and the usability of hemp seed in the product formulation. The nutritional values of hemp seed in the cookie samples demonstrated that it can be used as an alternative ingredient in the development of functional foods.

Securing Posterior Auricular Incision with Button Headbands in Prominent Ear Patients Wearing Surgical Masks for Self-protection in the Pandemic.

In this letter, we describe an attachment on conventional headbands recommended for the postoperative period in prominent ear patients to confidently wear surgical masks without disturbing the posterior auricular incision. 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 .

A Custom-Made Nostril Retainer for Adult Population.

Nostril retainers are used in cleft lip nose surgery in the post-operative period to maintain alar diameter and resistance against contraction. Various custom made splints were described in the literature to mimic this function when nostril retainers cannot be used for economic or logistic reasons. The authors designed a nostril retainer made by silicone urinary catheter for adult age patients which can be prepared easily. The splint can be used in both unilateral cleft lip nose surgery and operations in the alar wing of the nose.

A Practical Cleft Palate Training Model.

Educational models are essential for training surgeons and making them familiar with experience- and skill-dependent operations such as cleft palate closure. The development of computer and 3D printer technology has allowed cleft lip and palate models to be produced and used for surgical training. However, these technology-dependent models are not affordable and reproducible for surgeons in developing countries where cleft cases are more commonly seen. Thus, we aimed to create a cleft palate educational model prepared with play-dough and latex. The play-dough is shaped in the form of a palate and the cleft is created by scissors. Then, a latex glove is cut and applied to the dough to mimic the mucosal layer. The combination of the latex glove and play-dough lets the trainee perform surgical markings, incisions, elevation of the flaps, and layer closure. We think this easily producible model might be beneficial for demonstrating cleft types, surgical techniques, and improving surgical skills, especially in developing countries.

A New Oval Advancement Flap Design for Reconstruction of Pilonidal Sinus Defect.

BACKGROUNDS: Pilonidal sinus is a common chronic disease of the sacrococcygeal region. Although many surgical methods have been described for treating pilonidal sinus disease, controversy still exists as to the best surgical technique. The aim of this study is to present a new modified advancement flap technique named "omega flap" for the treatment of pilonidal sinus disease. MATERIALS AND METHODS: This study included 18 patients with pilonidal sinus who were treated between March 2012 and August 2014. All cases underwent oval excision and omega advancement flap reconstruction. Defect size, postoperative complications, postoperative pain, painless sitting time, patient satisfaction and recurrence were evaluated retrospectively. RESULTS: All patients were discharged on the first postoperative day. There was no flap necrosis. No recurrence and no major complication were observed during follow-up period. The outcomes were also satisfactory regarding functionally and aesthetically, and the patients were satisfied with the results. CONCLUSIONS: Presented method has a different geometry than classical advancement flap methods. Our technique provides two-layered repair with minimal tension and off-midline closure for the reconstruction of pilonidal sinus defect. It is easily performed, reliable, associated with no recurrens and good aesthetic results.

Nonmelanoma Skin Cancers in Solid-Organ Transplant Recipients: A Single Center Experience.

OBJECTIVES: Skin cancers are one of the most common malignancies in solid-organ transplant recipients. Increased age and immunosuppressive drug use are risk factors for posttransplant skin malignancies. We evaluated nonmelanocytic skin cancer incidence and development time in transplant patients. MATERIALS AND METHODS: We reviewed 1833 patients who received kidney, liver, and heart grafts between 1996 and 2016 at Baskent University. We excluded melanocytic skin cancers, premalignant lesions, and benign skin tumors. RESULTS: Of 1833 patients, 1253 were male (68.4%) and 580 were female (31.6%), composed of 1133 kidney (61.8%), 512 liver (27.9%), and 120 heart recipients (6.5%). Of these, 22 patients (18 kidney/3 liver/1 heart) developed 23 different types of skin cancer. Prevalence of skin cancer was 1.20%. Mean age at presentation was 55.8 years (range, 37-71 y). Average time from transplant to skin malignancy was 6.1 years (range, 1-13 y), with the most common being basal cell carcinoma (43%, 10 cases), followed by squamous cell carcinoma (39%, 9 cases) and Kaposi sarcoma (13%, 3 cases). Tumor sites included head and neck (15 case), trunk (2 cases), lower extremity (2 cases), and upper extremity (2 cases). Neither local recurrence nor distant metastasis was shown. CONCLUSIONS: Skin cancer risk is increased in solid-organ transplant recipients versus the general population. Although squamous cell carcinoma is the most common tumor in this patient population, followed by basal cell carcinoma, we found this reversed in our patients. The low prevalence of skin malignancy (1.20%) may be associated with close clinical follow-up to detect premalignant skin lesions and the lowdose immunosuppressive drug regimen. We believe that local recurrence and distant metastasis were absent because we use a wide surgical margin of excision and provide strict follow-up. Routine dermatologic follow-up visits of transplant recipients are recommended to detect and treat early skin cancer and premalignant lesions and thus lower morbidity and mortality.

Aesthetic Surgery in Transplant Patients: A Single Center Experience.

OBJECTIVES: Transplant patients, like the nontransplant population, can have surgical interventions for body shape disorders. Studies on aesthetic surgeries in transplant patients are scarce. Our aim was to share our experiences with various aesthetic procedures in solid-organ transplant recipients. MATERIALS AND METHODS: Six (5 female, 1 male) transplant patients who received surgical corrections of the aging face, ptosis and lipodystrophy of the breast, and abdomen at the Baskent University Plastic Reconstructive and Aesthetic Surgery Department between 2010 and 2017 were included. Five patients had renal transplants, and 1 patient had liver transplant. Minimal aesthetic procedures, including botulinum toxin, dermal filler injections, and scar revisions, were excluded. All patients were consulted to transplant team preoperatively and hospitalized in the transplant inpatient clinic. RESULTS: Mean age was 46 years. Aesthetic surgeries included breast reduction (2 patients), high suprasuperficial musculoaponeurotic system face lift (1 patient), blepharoplasty (2 patients), and dermofat grafting (1 patient). Mean hospitalization duration was 2.5 days. Four patients had no minor or major complications. One patient had skin flap necrosis, which healed with secondary intention. Another patient had ectropion after lower lid blepharoplasty, which was corrected with another procedure. CONCLUSIONS: Transplant patients are a special group of patients who receive long-term immunosuppressive treatment and medications like high-dose steroids. These treatments can lead to dermal atrophy and cause pseudo-skin laxity. Removal of excess skin and fat tissue should be considered. Efforts should be made to avoid complications such as skin necrosis and unpredictable wound healing problems when resecting the excess tissue. Preoperative consultation with transplant surgeons and keeping operative times short are other important factors. Body dysmorphologies that interfere with normal life activities and demand for younger appearance are the main reasons of aesthetic procedures. Transplant patients can be operated safely with preoperative planning, consultation with transplant surgeons, and close follow-up.

The effect of adipose derived stromal vascular fraction on stasis zone in an experimental burn model.

BACKGROUND: Stasis zone is the surrounding area of the coagulation zone which is an important part determining the extent of the necrosis in burn patients. In our study we aim to salvage the stasis zone by injecting adipose derived stromal vascular fraction (ADSVF). METHODS: Thermal injury was applied on dorsum of Sprague-Dawley rats (n=20) by the "comb burn" model as described previously. When the burn injury was established on Sprague-Dawley rats (30min); rat dorsum was separated into 2 equal parts consisting of 4 burn zones (3 stasis zone) on each pair. ADSVF cells harvested from inguinal fat pads of Sprague-Dawley rats (n=5) were injected on the right side while same amount of phosphate buffered saline (PBS) injected on the left side of the same animal. One week later, average vital tissue on the statis zone was determined by macroscopy, angiography and microscopy. Vascular density, inflammatory cell density, gradient of fibrosis and epithelial thickness were determined via immunohistochemical assay. RESULTS: Macroscopic stasis zone tissue viability (32±3.28%, 57±4.28%) (p<0.01), average number of vessels (10.28±1.28, 19.43±1.72) (p<0.01), capillary count (15.67±1.97, 25.35±2.15) (p<0.01) vascular density (1.55±0.38, 2.14±0.45) (p<0.01) epithelial thickness (0.014±0.009mm, 0.024±0.0011mm) were higher on ADSVF side. Fibrosis gradient (1.87±0.51, 1.50±0.43) (p<0.01) and inflammatory cell density (1.33±0.40, 1.20±0.32) (p<0.01) were higher on the PBS side. CONCLUSION: Macroscopic and microscopic findings determined that ADSVF has a statistically significant benefit for salvaging stasis zone on acute burn injuries.