The effect of educational internships on medical students' perceptions of plastic surgery.

OBJECTIVE: To investigate the effects of plastic, reconstructive and aesthetic surgery educational internships on medical students' perceptions of the scope of plastic surgery. METHODS: This cross-sectional study was conducted at the Gulhane Medical Faculty, Ankara, Turkey, from 2012 to 2013, and comprised 4th-, 5th- and 6th-year medical students. Students were given a questionnaire consisting of 28 questions related to maxillofacial and upper and lower extremity medical conditions, and skin, aesthetic and congenital anomalies. They were asked to correlate the treatment of certain medical conditions to the correct specialist clinics. SPSS 19 was used for data analysis. RESULTS: Of the 145 participants, 65(44.83%) had received internship education of plastic surgery while 80(55.17%) had not received internship training. In 27(96.4%) of the 28 medical conditions covered, patient referral to plastic surgery specialists was found to be significantly higher in the student group that participated in educational internships (p<0.05). For this same group of students, certain medical conditions, such as ptosis, pressure sores, parotid gland masses, venous ulcerations, facial nerve paralysis, septum deviations and large soft tissue defects with open tibia fracture, were less commonly referred to plastic surgery (<50% each). CONCLUSIONS: Short duration of educational plastic surgery internships prevented instructors from giving complete and detailed information to their students.

Oculoauriculofrontonasal Dysplasia Syndrome With Additional Clinical Features.

Oculo-auriculo-vertebral spectrum and frontonasal dysplasia are two well-known examples of dysmorphology syndromes. Oculoauriculofrontonasal syndrome (OAFNS) is a clinical entity involving the characteristics of both OAVS and FND and is thought to be a result of the abnormal development of structures in the first and the second branchial arches, including the abnormal morphogenesis of maxillary processes. Herein we report a case of OAFNS with cliteral hypertrophy, premaxillary teeth, and inguinal hernia, features not previously reported in the literature.

Effects of transpositional muscle flaps transfected with vascular endothelial growth factor gene in the treatment of experimental osteomyelitis.

BACKGROUND: Based on the angiogenetic and stimulating effects of bone healing and formation of vascular endothelial growth factor (VEGF), the present study was designed to assess the efficacy of VEGF gene application in the management of experimentally induced osteomyelitis. METHODS: Thirty-two male Sprague Dawley rats were divided into 4 groups, and osteomyelitis was induced in the left tibial bones. Group 1 (n=8) was designated as a control group, and, after the induction of osteomyelitis, no treatment was applied for a period of 4 weeks. Group 2 (n=8) received only antibiotic treatment for 4 weeks following induction of osteomyelitis. In Group 3 (n=8), proximally pedicled gastrocnemius muscle flap was transposed over the osteomyelitic region following induction of osteomyelitis and antibiotic treatment applied for a 4-week period. In Group 4 (n=8), VEGF gene-transfected gastrocnemius muscle flap was transposed over the osteomyelitic region following identical antibiotic regimen applied for a 4-week period. For each group, body temperature, white blood cell (WBC) count, and radiological and histological parameters were evaluated. RESULTS: Body temperature and WBC count remained high in the control group, but returned to normal in Groups 2, 3, and 4 after the third week of treatment. Statistical analysis of the total scores of radiological and histological results revealed significant differences between Groups 1 and 3, Groups 1 and 4, Groups 2 and 3, and Groups 2 and 4 (p<0.05). Regarding radiological parameters of abscess and sequester, and histological parameter of abscess, statistically significant differences were found between Group 4 and the other groups (p<0.05). CONCLUSION: The efficacy of the VEGF gene-transfected muscle flap in the management of experimental osteomyelitis was proven by the results of the present study.

Palmar contracture release with arterialized venous instep flap: An anatomical and clinical study.

BACKGROUND: Plantar skin has similar histologic features to the palmar area and appears to be the ideal tissue for reconstruction of the palmar region. In this study, an anatomic examination was performed to determine the superficial venous architecture of the instep area, and the use of arterialized venous instep flaps for palmar contracture release was assessed. METHODS: The anatomical study was performed on 12 fresh cadaver feet. The arterialized venous instep flap, including the skin, subcutaneous tissue and superficial venous plexus, was harvested. To determine the venous structure, dissection (n = 6) and injection-corrosion (n = 6) techniques were used. In the clinical study, nine arterialized venous instep flaps were used for palmar contracture release. All flaps were harvested above the deep fascia and included skin, subcutaneous fat, and the superficial venous plexus. At the plantar site of the flap, two or three veins, one of which was used, were dissected for a sufficient length for the arterial anastomosis. The saphenous vein was used for the venous anastomosis. RESULTS: Dissection and injection-corrosion techniques revealed that the flap had 7-12 and 4-6 veins at its plantar and superior edges, respectively, with numerous anastomoses and interconnections between the veins. The flap dimensions were between 3 × 5 cm and 4 × 6 cm. All flaps survived, with two partial flap necrosis that healed with spontaneous epithelization. No debulking procedures were undertaken and all flaps adapted well to the recipient site. CONCLUSIONS: The arterialized venous instep flap is a good alternative to reconstruct palmar contractures by adding similar tissue that is thin and pliable with minimal donor site morbidity.

Evaluation of the results of simultaneous open rhinoplasty and Abbe flap for the reconstruction of the secondary bilateral cleft and nasal deformity.

AIMS: We aimed to evaluate the results of simultaneous rhinoplasty and Abbe flap for the reconstruction of the secondary bilateral cleft and nasal deformity by means of a newly developed software-based method. PATIENTS AND METHODS: A total of 16 patients with the bilateral cleft lip nasal deformity received Abbe flap and simultaneous open rhinoplasty between 2004 and 2010. The mean age of the patients was 21 years, and the average follow-up time was 2.4 years. After the open rhinoplasty procedure, the upper lip was reconstructed with the Abbe flap. Preoperative and postoperative photographs that had been taken laterally were evaluated by using Adobe Photoshop(®) CS4 and Adobe InDesign(®) software. The length of the columella and the relative changes of the most anterior point of the upper lip to the vertical plane tangent to the most anterior point of the lower lip were measured in pixels on standardized preoperative and postoperative images. The differences were calculated and compared as a percentage (%). RESULTS: There was no flap loss and associated problems. The measurements of columellar length revealed an average increase of 51.8 ± 11.3%, while the relative change of the most anterior point of the upper lip revealed an average increase of 68.6 ± 11.2%. CONCLUSION: The results of the treatment modality were successfully evaluated by a newly developed software-based method.

Our experiences on the reconstruction of lateral scalp burn alopecia with tissue expanders.

INTRODUCTION: Cicatricial alopecia is a form of hair loss that causes both cosmetic and psychological concerns. Although tissue expanders are the common approach to reconstruction, no algorithm exists in the literature for this process. In this study, it was aimed to create an algorithm for the reconstruction of lateral scalp alopecias with the goal to achieve better and standardized results. MATERIALS AND METHODS: Lateral scalp alopecias were divided into three groups: total lateral alopecia (type I), temporal and sideburn alopecia (type II), and sideburn alopecia (type III). Tissue expanders were placed at the parieto-occipital area in type I defects, parietal area in type II defects, and the temporal region in type III defects. Tissue expanders were used to create flaps that were advanced with 60° rotation, 90° rotation, and no rotation for type I, II, and III defects, respectively. RESULTS: Fifteen patients were treated with this algorithm. Using this simple approach, we achieved natural, standardized aesthetic results for each patient, all of whom were satisfied with the final results. CONCLUSION: Although the number of case were limited, the ideal and standardized cosmetic results could be obtained by this approach.

A new flap alternative for trochanteric pressure sore coverage: distal gluteus maximus musculocutaneous advancement flap.

Management of long-term bedridden patients experiencing pressure sores still represents a surgical challenge due to limited flap alternatives and high recurrence rates after the treatment. Fasciocutaneous, musculocutaneous, local perforator-based flaps, and free flaps have all been used for treatment of trochanteric pressure sores. This study presents a new use of distal gluteus maximus (GM) muscle as an advancement musculocutaneous flap for coverage of trochanteric pressure sores in 7 patients. The technique involves design of a long V-shaped skin island over the distal fibers of the GM muscle, beginning from the inferoposterior wound edge and extending inferomedially, almost parallel to the gluteal crease. After its harvest as an island flap on the distal fibers of the GM muscle, the skin paddle can be advanced onto the trochanteric defect, whereas the muscle itself is rotated after severing its insertion to femur. If a second triangular skin island is designed on the proximal fibers of GM muscle to cover an associated sacral defect, 2 coexisting pressure sores can be reconstructed concomitantly with 2 skin paddles on a single muscle belly at 1 surgical setting. Of the 7 patients, 3 had 3 (bilateral trochanteric and sacral), 2 had 2 (sacral and trochanteric), and 2 had 1 (only trochanteric) pressure sores. All ulcers were closed successfully and all of the flaps survived totally without any complication except the one in which we experienced minimal wound dehiscence in the early postoperative period. Conclusively, our current surgical method provided a reliable coverage for trochanteric pressure sores although it was technically straightforward and fast. Additionally, it offers simultaneous closure of 2 pressure ulcers with 2 skin islands on a single muscle flap.

Auto-/homografting can work well even if both autograft and allograft are meshed in 4:1 ratio.

BACKGROUND: Patients suffering major burns of more than 50% total burn surface area lack an adequate skin graft donor site to resurface extensive burn wounds and usually need widely meshed autografting and allografting. Anything over the 3:1 expansion ratio is strongly associated with low graft take, poor or delayed epithelialization, and hypertrophic scarring. METHODS: In this study, both autografts and allografts were expanded at a 4:1 ratio. We aimed to use skin grafts effectively and to decrease the morbidity due to graft harvesting. Nine patients with major burns were treated with this method. Graft gain ratio and percentage of actual expansion to predicted expansion were calculated. RESULTS: Ten auto-allografting procedures were performed on a mean of day 16. Graft take was over 95% successful. Five patients survived, and four patients died. The mean total burn surface area was 58.8% in patients who recovered, and 77.5% in the patients who died. The graft gain ratio was 74.8%. The actual expansion rate was 43.7% of the predicted expansion rate. CONCLUSION: In this study, we demonstrated that the donor site morbidities were reduced and successful epithelialization was completed on the eighth day after using both autograft and allograft meshed with a 4:1 ratio.

Free fibular flap vascular pedicle calcification.

Osseous free flaps are major reconstruction choices of the segmental mandibular defects. However, etiology of defects in mandible is variable; tumor-related surgery, trauma, radiation, or congenital anomalies are the most common causes. The advent of microvascular surgery has achieved the reconstruction of complex mandibular defects. The options for bony free-tissue transfer for mandibular reconstruction primarily depend on the fibula, iliac, scapula, and radius bone. The free fibular flap continues to be first choice in the reconstruction of mandibular defects because of its advantages. In this report, rare complication of vascular pedicle calcification after mandibular reconstruction with free fibular flap is presented.

Cerium nitrate treatment prevents progressive tissue necrosis in the zone of stasis following burn.

Cerium nitrate (CN) was used as a topical antiseptic agent for the treatment of burn wounds and found to reduce the number of anticipated death in burn. This decreased burn related mortality cannot be explained by the control of wound infection alone. In the studies performed to elucidate the unexplained effects of CN treatment, it was shown that CN treatment reduced the alarm cytokine levels, decreased leukocyte activation, reduced macromolecular leakage and finally burn edema formation. We hypothesized that CN treatment prevents the conversion of the zone of stasis to progressive tissue necrosis by decreasing leukocyte activation and reducing macromolecular leakage and burn edema. This was investigated on a well-described burn comb model in the rats. Fifty-four rats were randomly divided into control and CN treatment groups. Each rat in CN treatment group received 0.04 M CN bathing 30 min after burn whereas rats in control group received 0.09% saline bathing. Viability of zone of stasis is assessed with (99 m)Tc-sestamibi scintigraphy. Nine rats in each group were scintigraphically evaluated at the 3rd and 7th day after burn and remaining 9 rats had macroscopic and histological examination at the 21st day after burn to confirm the scintigraphic results. In CN treatment groups, the scintigraphic uptake ratios were higher both at post burn day 3rd and 7th when compared to that of control groups. This was statistically significant (p≤0.05). In the CN treatment group, the results of the average percentage of the re-epithelialization in the zone of stasis were higher than that of control groups. The difference between the groups was also statistically significant (p≤0.05). These results were accepted that CN treatment prevents progressive tissue necrosis in the zone of stasis. This study further elucidates the unexplained effects of CN treatment on burn.

Hair transplantation for therapy-resistant alopecia areata of the eyebrows: is it the right choice?

Alopecia areata is a common skin disorder of presumed autoimmune etiology and it usually shows an unpredictable course. Treatment of alopecia areata is challenging. There is very little information on the use of surgical therapies for the treatment of alopecia areata in the medical published work. A 24-year-old male patient was referred to a private hair transplantation clinic owned by one of the authors for the treatment of therapy-resistant alopecia areata affecting both eyebrows. He had quickly lost all body hair 4 years prior beginning from the scalp. He received psoralen and ultraviolet A (PUVA) therapy for alopecia universalis and all body hair re-grew except his eyebrows. Alopecia areata was stable for the 18 months following the last medical treatment he received. Because there was no response to various medical therapeutic agents, we decided to transplant occipital hairs to the eyebrow area. After the patient understood and accepted all risks, occipital hairs were transplanted to the eyebrows by using the follicular unit extraction technique. Postoperatively, the patient did not receive any topical or systemic therapies for alopecia areata. Although 40% hair re-growth was detected in his eyebrows at 1 year postoperation, this rate was 80% by 2 years postoperation. However, there was resistance to re-growth in the medial eyebrow regions. New eyebrows grew as occipital hairs and required trimming. His satisfaction from the surgical procedure was 90% at the end of the 24th postoperative month. Surgical treatment of diseases like alopecia areata is still controversial. Our case report offers an additional contribution to the published work on the surgical methods used in the treatment of stable alopecia areata.

Saving the zone of stasis in burns with activated protein C: an experimental study in rats.

Salvage of the zone of stasis is a major subject of focus in burn research. Use of various antithrombotic, anti-inflammatory and antioxidant drugs have been studied experimentally, with reports of favourable results; however, none became popular in clinical practice. Activated protein C (APC) is a well-known physiologic anticoagulant. Recent studies revealed that APC contributes not only to systemic anticoagulant activities but also to anti-inflammatory activities by inhibiting leucocyte activation associated with TNF production. The likely favourable effects of APC on salvage of the zone of stasis were investigated on a well-described experimental rat burn model representing the zone of stasis according to the 'burn comb model'. Twenty Sprague-Dawley rats were used and randomly separated into experimental and control groups. Two hours after inducing injury, 100 microg kg(-1) APC (Sigma, Boehringer Ingelheim, Germany) was administered to the experimental group through the caudal vein while 0.9% saline was injected through the same route in the control group. Laser Doppler flowmetry measurements and autoradiography were used for evaluation of perfusion and viability in the zone of stasis. At day 3, the differences between the results obtained from the treatment and the control groups were found to be statistically significant (p<0.05). Our experimental study revealed that APC improved tissue perfusion and decreased the area of skin necrosis in the zone of stasis in rats. The dual effect of APC, each of which has been shown to be favourable in saving the zone of stasis, may make this agent effective with a single effect in treatment of burn injury.

Treatment of temporomandibular joint ankylosis and facial asymmetry with bidirectional transport distraction osteogenesis technique.

Transport distraction technique is a good treatment modality for unilateral temporomandibular joint ankylosis. However, with a unidirectional distraction, it is not possible to correct facial asymmetry that results from mandibular hypoplasia associated with early-onset unilateral temporomandibular joint ankylosis. For this purpose, gap arthroplasty and simultaneous bidirectional transport distraction was used to correct these deformities. Although vertical distraction corrects vertical deficiency of the ramus and creates a neocondyle, the simultaneous anteroposterior distraction of the transport segment corrects facial asymmetry resulting from horizontal shortness of mandible. Three patients, whose mean mouth opening was 8.6 mm, were successfully treated with this technique. Mean advancements in vertical and anteroposterior direction were 14.7 and 7.7 mm, respectively. Mean maximal mouth opening was 29.7 mm postoperatively. The average follow-up period was 13 months (range, 12-15 mo). During this period, reankylosis was not observed, and the interincisal distance did not decrease. Gap arthroplasty and bidirectional transport distraction of the mandibular ramus is a good and effective therapeutic option in treatment.

A new finger fillet design from an index finger with severe postburn flexion deformity.

Treatment of postburn deformities of the hand is a real challenge to reconstructive surgeons. A functional reconstruction was achieved with two sensate island flaps on two discrete pedicles in a case with severe postburn deformity involving both thumb and index finger. Surgical treatment was based on amputation of the second ray and reconstruction of the thumb with the flaps derived from the discarded index finger. Two sensate island flaps on two discrete pedicles, "1st dorsal metacarpal artery based flap" from the dorsal aspect of the proximal phalanx and "palmar digital artery based fillet flap" composed of available volar skin of the index finger distal to contracture, were harvested and used for replacement of the soft tissue defect of the thumb that appeared after correction of bone and joint deformities. Both of the flaps survived and functional improvement was satisfactory at one-year follow-up. Despite the shortening of neurovascular bundles due to severe flexion deformity, a sensate thumb reconstruction with a better tissue match was achieved thanks to more beneficial design and orientation of two neorovascular island flaps from a deformed index finger. Instead of a single fillet flap design in its common use, our current approach allowed more beneficial use of a discarded index finger in severe postburn deformity involving both thumb and index finger.

Thalidomide decreases the plasma levels of IL-1 and TNF following burn injury: is it a new drug for modulation of systemic inflammatory response.

TNF and IL-1, which are produced from phagocytic cells, can produce a significant systemic inflammatory response independently by inducing systemic leukocyte and endothelial cell activation. These cytokines play a pivotal role in development of systemic inflammatory response after severe burn. Thalidomide has been shown to decrease the secretion of TNF from phagocytic cells, therefore suppression of TNF and IL-1 production from activated phagocytic cells might be a successful treatment modality for prevention of systemic inflammatory response following severe burn. To address this issue, we aimed to show whether thalidomide treatment decreased or suppressed plasma levels of TNF and IL-1 following burn in rats. Following the injury, 36 rats were randomly separated into two experimental groups at the third and seventh days. Rats in the experimental group had oral thalidomide (10mg/kg day) treatment for three and seven consecutive days whereas animals in control groups had no treatment. Thalidomide treatment decreased TNF and IL-1 significantly in both experimental groups at both the points (P<0.05). Although in this study we just showed inhibitory effect of thalidomide on plasma the level of TNF and IL-1, we speculate that thalidomide may have modulatory effect on the systemic inflammatory response after burn by decreasing plasma levels of TNF and IL-1.

Contour restoration of the secondary deformities of zygomaticoorbital fractures with porous polyethylene implant.

Inappropriate treatment or untreated fractures of the zygomaticoorbital area results in secondary deformities such as loss of malar projection, enophthalmos, and dystopia. Secondary deformities can be corrected with osteotomies, contour restoration, or a combination of both. Contour restoration can be performed with using onlay grafting with autogenous material or alloplastic implants. In this study, mild to moderate secondary deformities of zygomaticoorbital fractures were corrected with porous a polyethylene implant, which is a highly biocompatible, durable, and stable material. The number of patients who have no surgical treatment at the time of their initial injury was 15, whereas the number of patients who have an initial treatment that resulted in secondary deformities was seven. Twelve of 15 patients had only loss of cheek projection and three of the 15 patients had dystopia and loss of cheek projection. The remaining seven patients had secondary deformities resulting from skeletal surface contour abnormality as a result of comminuted fractures. In 17 of the patients, we used a subciliary approach while using the old incision scar for access in the remainder. In 22 patients, 24 implants were used. Porous polyethylene implant was carved outside in according to the existing contour deficit and was placed in the subperiosteal plane and fixed with titanium screws. The mean follow-up period was 13 months (range, 6-24 months). In this follow-up period, there was no implant extrusion, exposition, infection, or any complication resulting from subciliary incision. Patients were satisfied with the results. The best result can be achieved with porous polyethylene implant in contour restoration of mild to moderate secondary deformities of zygomaticoorbital fractures. The use of this implant in the zygomaticoorbital area is safe and has minimal morbidity.

Assessment of distraction regenerate using quantitative bone scintigraphy.

In this study, we examined whether quantitative bone scintigraphy can be used to assess new bone formation following distraction osteogenesis (DO). A vertical osteotomy was performed on the right hemimandible of male Sprague-Dawley rats, and a custom-made distraction device was applied. Following the gradual distraction, rats were divided into 2 subgroups, the second and fourth week. Cephalograms were taken and scintigraphic and histomorphometric analysis was performed at the second and fourth week. Scintigraphic findings showed good correlation with histomorphometric results. Results were compared with sham-operated (skin and muscle incision and placement of pin but no osteotomy) and acute distraction (5-mm acute distraction) groups. Scintigraphic mean uptake ratios were significantly higher in the gradual distraction group compared with the sham-operated and acute distraction groups. Quantitative bone scintigraphy is a promising method for the assessment of DO and consolidation. It could offer objective qualitative and quantitative data for the noninvasive evaluation of bony regenerate.