De Novo Malignancies After Kidney Transplant: Where Do We Stand and Does the Head and Neck Region Require More Caution?

OBJECTIVES: The aim of this study was to investigate the characteristics of de novo malignancies arising in kidney transplant recipients followed in a tertiary hospital in Turkey and to examine the tumors in the head and neck region as a subgroup. MATERIALS AND METHODS: Data from kidney transplant recipients treated at our institution between January 2010 and July 2022 were retrospectively analyzed in this single-center study. Data regarding malignancies were noted according to the pathologists' reports. In situ malignancies and those arising after graft loss were not evaluated. RESULTS: The study population comprised 231 patients (165 men; 71.4%) with a median follow-up of 11 years (2853 patient-years). The recipients had a higher cancer risk than the general population (standardized incidence rate = 3.04; 95% CI, 1.82-4.26). Thirty de novo malignant tumors were detected in 24 patients (10.4%). The mean age at diagnosis of cancer was 54.88 ± 11.44 years. The median time from transplant to cancer diagnosis was 11.5 years (range, 7-18.8 y). Nonmelanoma skin cancers (56.7% of all tumors) were the most common malignancies. Twenty-two lesions (73.3%) that developed in 17 patients (7.4%) were localized to the head and neck region: 15 (68.2%) were cutaneous and 7 (31.8%) were noncutaneous. The median time from transplant to head and neck cancer diagnosis was 12 years (range, 7.5-17.5 y). Mortality rate was higher in cancer patients (10 [41.7%] vs 17 [8.2%]; P < 0.01). CONCLUSIONS: The incidence of de novo malignancy in kidney transplant recipients was relatively higher compared with previous data. Nonmelanoma skin cancers were the most common type. Three-quarters of all lesions were in the head and neck region, and two-thirds were of cutaneous origin.

Reconstruction of Orbital Floor With Auricular Concha.

Orbital floor fractures of varying sizes commonly occur after orbital injuries and remain a serious challenge. Serious complications of such fractures include enopthalmos, restriction of extraocular movement, and diplopia. There is a dearth of literature that can be applied widely, easily, and successfully in all such situations, and therefore there is no consensus on the treatment protocol of this pathology yet. Autogenous grafts and alloplastic and allogenic materials with a wide variety of advantages and disadvantages have been discussed. The value of preoperative and postoperative ophthalmological examination should be standard of care in all orbital fracture patients. An ideal reconstructed orbital floor fracture should accelerate the restoration of orbital function with acceptable cosmetic results. Management parameters of orbital fractures such as timing of surgery, incision type, and implant materials, though widely discussed, remain controversial. In this study, 55 patients with orbital floor fractures surgically reconstructed with conchal cartilage grafts between 2008 and 2014 were retrospectively evaluated. Complications and long-time follow-up visit results have been reported with clinical and radiographic findings. The aim of this study was to present the authors' clinical experiences of reconstruction of blow-out fractures with auricular conchal graft and to evaluate the other materials available for use.

Comparison of Subciliary Approaches in Orbito-Zygomatic Fractures: Skin Flap Versus Skin-Muscle Flap.

BACKGROUND: Because of the complications of classical subciliary incision, some modified subciliary approaches have been described in recent literature. OBJECTIVES: The aim of this study was to compare 2 commonly used subciliary approaches according to development of postoperative complications (scar formation, and ectropion). MATERIALS AND METHODS: Ninety patients were included in this retrospective study. Subciliary skin flap technique (SF group) was performed to 39 patients, while the others were operated by using skin-muscle (stepped) flap technique (SMF group). Fitzpatrick skin types, genders, ages, scar scores, and ectropion scores of the patients also were recorded. RESULTS: The mean age of the patients was 39.3 (18-99) years, and the mean follow-up period was 2.1 (1-6) years. Fitzpatrick skin-type levels were between 2 and 4 (median = 3). No difference was found between 2 groups in terms of age, follow-up period, and Fitzpatrick skin-type levels. However, the scar values of the SMF group were significantly lower than the SF group statistically. Also, there was no significant difference between males and females in SF and SMF groups in terms of scar and ectropion formation. On the other hand, scar values were lower in SMF groups rather than SF group in males. Although ectropion values were not different between SF and SMF groups in females, ectropion values of SMF group were significantly lower than SF group in males statistically. CONCLUSION: Subciliary skin-muscle (stepped) flap technique can be more reliable than subciliary skin flap technique for approach to orbitozygomatic fractures.

Orbicularis oculi myocutaneous advancement flap for upper eyelid reconstruction.

BACKGROUND: Reconstruction of large full-thickness defects of the upper eyelids is challenging because of their complex anatomy and specialized functions. The authors present and discuss a new, simple surgical technique for upper eyelid reconstruction. This is a single-stage procedure and has produced satisfactory to excellent results in the authors' patients. It presents the reconstructive surgeon with several advantages over other techniques. METHODS: The eyelid tumor is excised surgically until clear margins are obtained. The V-shaped orbicularis oculi myocutaneous advancement flap is marked on the remaining superior eyelid tissue and mobilized, leaving the base of the pedicle intact with submuscular tissue attachment. Posterior lamella reconstruction is performed with mucoperiosteal graft harvested from the hard palate in patients with full-thickness defects. Then, the flap is advanced to the defect and the donor site is closed primarily. RESULTS: Eight patients, aged 17 to 72 years, have been operated on with this technique for upper eyelid reconstruction. Follow-up included assessment of position, closure, length of palpebral rim, eyelid opening, aesthetic balance, presence of corneal erosion, ulcer or entropion, levator function, and donor-site morbidity. The flap was viable in every patient, without total or partial necrosis. No patient required surgical revision. The oncologic result was good, and no recurrence was noted. CONCLUSIONS: This method is a simpler, single-stage operation; does not damage the lower lid; provides a thin, mobile eyelid; and, above all, is less invasive than other techniques, and at the same time allows a good functional and aesthetic reconstruction.

Use of the medial side of the knee skin as a free flap: saphenous flap.

BACKGROUND: The knee region is a good free skin flap donor site, as it has minimal subcutaneous tissue and provides a hidden donor site. Acland et al. first used the skin over the medial side of the knee as a "saphenous flap" based on the saphenous branch of the descending genicular artery. METHODS: The authors studied the descending genicular artery and its saphenous branch in six cadaver limbs and elevated the skin over the medial side of the knee as a free flap in six patients to reconstruct lower extremity defects. RESULTS: In all clinical cases, the authors were able to elevate a skin flap from the skin on the medial side of the knee. The saphenous branch was absent in one cadaveric limb and one patient limb; instead, a direct cutaneous branch from the femoral artery reached the skin and had nearly the same caliber as the saphenous branch of the other cases. All the flaps survived and the defects healed well. CONCLUSION: The medial side of the knee is a good donor site, as it provides thin skin with innervation potential by means of the medial femoral cutaneous nerve and leaves an inconspicuous donor-site scar.

Reconstruction of the columella with bilateral nostril sill flaps.

The treatment of total columellar defects is very difficult, and there is not any first choice in reconstruction of these defects. Various techniques have been reported for this purpose. Each technique has its own drawbacks, and few can be performed in one stage. We report a pediatric patient with a defect involving the entire columella. Reconstruction of the defect was accomplished with laterally based bilateral nostril sill flaps. An acceptable cosmetic result was obtained. This method can be done as a single-stage operation with an excellent color and texture match. We think that this method leads to good aesthetic results, and should be considered for total columellar reconstruction.

Urethral advancement for recurrent distal hypospadias fistula treatment.

Hypospadias fistula may be persistently recurrent in some patients. In distal hypospadiac fistula cases, carrying the fistulous opening to the glans tip may be possible with extensive urethral mobilization and advancement. In 9 patients who were operated for urethrocutaneous fistula, we used the urethral advancement technique. Patient ages ranged from 5 to 14 years (mean, 8 years). In all of the cases, the urethra was mobilized proximally to at least penoscrotal junction, and in some cases, the bulbar urethra was mobilized partially. Follow-up ranged from 6 months to 16 months. In all but 1 child, a straight penis with the neomeatus at the glans tip was maintained without any urethrocutaneous fistula. In 1 child, chordee, which was already present, could not be prevented.Urethral advancement technique may effectively solve the problem of persistently recurrent hypospadias fistula. We recommend the technique to plastic surgeons' armamentarium.

Rat penis as a replantation model.

The aim of this study is to assess the feasibility of rat penile replantation as a new microsurgical training model. The study was performed in 2 parts. ANATOMIC STUDIES: Fifteen Wistar albino rats were used to study and document the penile vascular anatomy. In 5 rats, dissections were performed after colored silicone injections, while 5 rats were operated under anesthesia to develop the strategy of flap elevation. In the remaining 5 rats, microangiographic study was performed with silicone-lead oxide mixture. FLAP STUDIES: As flap studies in 5 rats, penis were elevated based on right-side internal pudendal artery and internal pudendal vein and resutured. In 6 rats, penis were elevated as free flaps, and in 3 rats the penis were implanted in right thigh of the rats being the femoral artery and vein recipient. In the remaining 3 rats, penis were resutured in their original place, with saphenous artery and vein being the recipient and rerouted to the pubic region. At postoperative fifth day, the penis were examined for viability, and selected ones were histologically examined. Rat penis has a dual blood supply from bilateral internal pudendal arteries. Venous drainage is via both crural veins and dorsal vein. One side of the internal pudendal artery and anastomotic vein (branch of pudendal plexus) may be used as the vascular pedicle of the flap. Rat penis may be successfully elevated as a free flap and also may be replanted in its original place.

Use of medial arm skin as a free flap.

BACKGROUND: Free transfer of the medial arm flap has not gained popularity despite the hidden donor-site scar as well as the hairless and elastic skin. This may be because of variations in vascular anatomy, leading to confusion during dissection of the flap. METHODS: In five preserved cadaver arms, the vascular pattern of medial arm skin was examined. Twenty-two upper extremity angiograms were examined, and 12 free medial arm flaps were elevated for various defects in 12 patients. RESULTS: In cadaver and clinical dissections, the authors found that blood supply to the flap is multiple: from the superior ulnar collateral artery, the direct cutaneous artery, or both. A superficial brachial artery may also be present, which was observed in four angiograms and two clinical cases (15 percent). Dissections showed that the medial arm skin may be elevated based on the superficial brachial artery, direct cutaneous artery, or superior ulnar collateral artery. A neurosensory flap may be obtained by including the medial brachial cutaneous nerve of the arm. CONCLUSIONS: A medial arm free flap is a plausible reconstructive option with good knowledge of the anatomical variations, as the defect on the medial arm is cosmetically more acceptable and has a better color match for head and neck reconstructions.

Reverse-flow first dorsal metacarpal artery flap for index fingertip reconstruction.

Dorsum of the hand is an ideal skin-flap donor site for coverage of hand or finger defects. We elevated 8 reverse-flow first dorsal metacarpal artery flap in 9 patients for soft-tissue cover of index fingertip injuries distal to distal interphalangeal joint with exposed bone. In 3 patients, the digital branch of the superficial radial nerve was coapted to the digital nerve. All flaps healed uneventfully, except for 1 patient in which partial necrosis of the flap occurred. Postoperative follow-up was 4-12 months (mean, 8 months). Reverse-flow first dorsal metacarpal artery flap is a good alternative for reconstruction of index fingertip injuries.

Versatility of the lateral arm free flap in various anatomic defect reconstructions.

The free lateral arm flap may be harvested as a fascial, fasciocutaneous, or osteofasciocutaneous flap. Simultaneous flap elevation with preparation of the recipient site, easy dissection, minimal donor-site morbidity, and a constant vascular anatomy with long pedicle are advantages of the flap. In this study, the authors present 18 patients operated on between January, 2002 and August, 2003 in whom 18 free lateral arm flaps were utilized. There were four women and 14 men, and the mean patient age was 40 years. Thirteen fasciocutaneous, three fascial, and two osteofasciocutaneous flaps were used. Flaps were employed for the reconstruction of the lower extremity in five patients, upper extremity in nine patients, and head and neck in four patients. Thirteen flaps were elevated under axillary block and five flaps under general anesthesia. Aspirin, dipirydamol, dextran, and chlorpromazine were administered postoperatively. Venous insufficiency developed in two lower-extremity reconstructions on postoperative day 1. Venous thromboses were detected, anastomoses were re-done, and flaps healed uneventfully. No other postoperative complication was observed in the other patients. The free lateral arm flap may be used in various anatomic defects with various indications. It may be elevated under axillary block for extremity reconstructions.

A new epineural nerve repair technique with external metallic circle.

BACKGROUND: Despite the existence of various nerve coaptation techniques, functional results of nerve repair are still inadequate. Potential benefits of developing modified coaptation techniques cannot be disregarded. METHODS: The authors report a new coaptation technique in which the epineural sutures were performed with an external metallic circle to increase the coaptation surface. The sciatic nerves of 30 male Wistar albino rats were used in the study. RESULTS: The mean Sciatic Function Index values in external metallic circle repair (n:11) and conventional epineural repair (n:10) groups were -42.35 +/- 22.95 and -69.34 +/- 17.96, respectively (p = 0.020). Electrophysiological studies revealed that the duration of compound muscle action potentials (CMAP) was (p = 0,012) shorter in conventional nerve repair group than it was in external metallic nerve repair. When external metallic circle repair and conventional epineural repair groups were examined for distal nerve segments, there were significant findings for the diameter of axons (p = 0.005), diameter of nerves (p = 0.000), and for G ratios (p = 0.000). The mean intraepineural cross sectional areas of external metallic circle repair and conventional epineural repair groups were 3.57 +/- 0.21 and 2.92 +/- 0.23 mm(2), respectively (p = 0.000). CONCLUSION: The external metallic circle repair technique enhances nerve regeneration by enabling a larger sprouting and contact area for nerve fibers.

External metallic circle in hepaticojejunostomy.

BACKGROUND: Biliary-enteric anastomosis especially Roux-en Y hepaticojejunostomy is frequently used for biliary diversion in benign biliary strictures. In this study, we present the results of hepaticojejunostomy with external metallic circle. METHODS: Hepaticojejunostomy with external metallic circle were performed in eight male Sprague-Dawley rats. At the end of the third month, anastomoses were analysed for patency and stability of external circles. RESULTS: Relaparotomy revealed that all the anastomoses were patent and circles were in original places. CONCLUSION: To provide the patency of narrow hepaticojejunostomy anastomoses, external metallic circle can be a good alternative to use of internal stents in suitable cases.

Free microvascular transfer of coccygeofemoral muscle in rabbits.

A new experimental free flap model, the cocygeofemoral muscle flap of the rabbit, is introduced in this study. The coccygeofemoral muscle is a superficially located triangular muscle originating from the sacrum and inserting into the lateral condyle of the tibia, and it abducts the thigh. Anatomical dissection and microangiographic studies revealed that it has a major and a minor pedicle, the former originating from the caudal gluteal artery, and the latter originating from the caudal femoral artery. Its major pedicle contains the 0.7-mm artery, 1-mm vein, and the single nerve originating from the inferior gluteal nerve. In flap studies in 10 animals, the distal minor pedicle was ligated, and muscle was dissected up to its major pedicle and denervated, and the free muscle was transferred to the contralateral inguinal region via end-to-end anastomosis to the recipient vessels (i.e., the femoral artery and vein). At postoperative day 7, the transferred muscles were harvested and histologically examined. Nine of 10 muscles were viable; the coccygeofemoral muscle free flap is believed to be an easy-to-dissect and bulky flap model, having a relatively thick pedicle. It may serve as a good model in free muscle flap studies.