Specimen radiography: an assessment method for reduction mammaplasty materials.

Although, one out of every eight women has a risk of developing breast cancer, the reported incidence of breast carcinoma detection in reduction mammaplasty materials is rather low. To our knowledge, specimen radiography, which is used for breast biopsies has not been used for the assessment of breast reduction materials. We investigated the applicability of specimen radiography and its potential benefits in detection of the breast pathologies, especially malignancies in reduction mammaplasty materials. Forty patients scheduled for reduction mammaplasty operation were included. In all cases an inferior pedicle reduction technique was preferred and the radiographs of the resected breast tissues were taken immediately. The radiographs were evaluated for any possible pathologic appearance and all abnormal findings were marked. For the histopathologic evaluation, in addition to the random sampling of the pathologist, any marked areas were also microscopically examined. In two cases fibrocystic changes were found in radiographs and the same results were obtained in the histological examination. No false negative mammogram was seen. Specimen radiography, which is applicable for breast reduction materials is an easy and cheap method and does not cause any patient discomfort. It seems that the radiographs of reduction mammaplasty materials are useful to provide guidance to the pathologist during tissue sampling for microscopic examination especially when large amounts of breast tissue is excised.

Effect of warm ischemia on neovascularization of island flaps.

Poor neovascularization in free-flap transfers is considered to be a consequence of insufficient hypoxic stimulus in a transferred flap with good axial-pattern circulation and a short warm ischemia time. The purpose of the study was to investigate the effect of warm ischemia time on neovascularization of axial-pattern flaps. Oblique adipomusculocutaneous groin island flaps based on the superficial epigastric vessels were raised on the right side of 21 Wistar rats, evaluated in three groups. In Group 1 (n=7), flaps were resutured without creating ischemia; in Groups 2 (n=7) and 3 (n=7), flaps were resutured after 90-min and 180-min warm ischemic periods, respectively. At 5 days postoperatively, an intravenous fluorescein test was performed following pedicle ligation, and survival was assessed by planimetric technique 7 days after pedicle ligation. Histopathologic scoring was performed according to capillary formation, inflammation, and necrosis. The intravenous fluorescein test revealed significantly higher uptake in the group with the longest ischemic period, while the mean surviving area was greater in the groups with ischemic insult, comparing to the non-ischemic group. Similarly, histopathologic scoring showed significantly higher values in the ischemic groups. The authors demonstrated that neovascularization was enhanced after 90- and 180-min warm ischemia times. The authors concluded that short ischemia time in free flaps may be an attributable factor in late flap failures, due to pedicle obstruction.

The effect of gradually increased blood flow on ischemia-reperfusion injury.

Even with excellent operative techniques, prolonged ischemic periods may cause unwanted results because of a complex mechanism called reperfusion injury. Various pharmacological and immunological agents have been used to prevent this type of injury. Another known way to diminish reperfusion injury is the gradual reperfusion of the ischemic tissues. In this study, the effect of a gradual increase in blood flow on ischemia-reperfusion injury of the skeletal muscle was investigated. The right hind limbs of 15 rats were partially amputated, leaving the femoral vessels intact. Preischemic femoral arterial blood flow was measured by using a transonic small-animal blood flowmeter (T106) in all animals. The rats were divided into three groups: Group I consisted of control rats; no ischemia was induced. Group II was the conventional clamp release group. Clamps were applied to the femoral vessels to induce 150 minutes of ischemia. The clamps were then released immediately and postischemic blood flow was measured. Group III was the gradual clamp release group. After 150 minutes of ischemia, clamps were released gradually at a rate so that the blood flow velocity would reach one fourth the mean preischemic value at 30 seconds, one half at 60 seconds, three fourths at 90 seconds, and would reach its preischemic value at 120 seconds. Total clamp release was allowed when blood flow was less than 1.5 fold of the preischemic values. Postoperatively the soleus muscles were evaluated histopathologically, and malonyldialdehyde and myeloperoxidase levels were measured. The mean preischemic blood flow was 13.6 +/- 2.24 ml per kilogram per minute in all groups. In the conventional release group, postischemic flow reached four to five fold its preischemic values (61.06 ml per kilogram per minute). Histopathology revealed more tissue damage in the conventional release group. Malondialdehyde and myeloperoxidase levels were also significantly lower in the gradual release group. Depending on histological and biochemical findings, a gradual increase in blood flow was demonstrated to reduce the intensity of ischemia-reperfusion injury in the soleus muscle of this animal model.

A new animal model for tissue preservation.

In vivo preservation of tissues may exist as a problem in experimental and clinical research. Adipose tissue, nerves, and vessels are the tissues that are usually preserved in vivo for future use or for the evaluation of results in experimental research. Limited volume and difficult conditions in such areas in animal models usually create disappointing results, because of the difficulty in distinguishing the experimental from the surrounding tissues; the insufficiency of the volume of space; and the lack of compliance in animals. A new rat model for in vivo preservation studies is described. A muscular pocket designed between the external and internal oblique muscles is a good choice as an animal model for tissue preservation in plastic surgery research.

Extensive lymphatic malformation of penis and scrotum.

Lymphangioma circumscriptum is an uncommon condition of the skin and subcutaneous tissues characterized by localized patches of vesicles. The penoscrotal region is a rare site for its development. We present a case with an extensive onset of lymphatic malformation of the pubis and penoscrotal region that we treated with wide excision. Reconstruction was achieved with a split-thickness skin graft combined with residual scrotal skin advancement.

Cerebriform fibrous proliferation vs. proteus syndrome.

Proteus syndrome is a rare, congenital hamartomatous syndrome that presents with a wide range of abnormalities. Regardless of different manifestations found in different patients, there exists three mandatory criteria for the diagnosis of this syndrome: a mosaic distribution of the lesions, a progressive course, and sporadic occurrence. When these criteria are met, the presence of additional connective tissue nevi, which are encountered mostly on the plantar surface of the feet, suffices for the diagnosis of Proteus syndrome. The authors present a 48-year-old woman who had been evaluated for a lesion on the plantar aspect of her left foot that was diagnosed as keloid and was treated unsuccessfully. In the light of the literature and with the help of histopathological reevaluation, the authors thought this unique lesion may be a localized form of Proteus syndrome.

Oral commissure reconstruction with split masseter muscle transposition and cheek skin flap.

Satisfactory reconstruction of the cheek involving the oral commissure is always challenging. A 64-year-old male patient underwent full-thickness repair of a cheek defect involving the oral commissure following excision of squamous cell carcinoma. Reconstruction was performed with a cheek skin flap combined with split masseter muscle transposition. This method was found to be useful for reconstructing the oral commissure with good functional and aesthetic results.

Use of the turnover epineurial sheath tube for repair of peripheral nerve gaps.

Autologous nerve grafting is the conventional technique for bridging nerve gaps, despite its various disadvantages. In this study, the authors investigated the effects of the turnover epineurial sheath tube (TEST) as an alternative to nerve grafting for the repair of nerve gaps, using a rat sciatic nerve model in four groups: Group 1 (n = 5): sham control; Group 2 (n = 10): segmental nerve resection + no repair; Group 3 (n = 10): segmental nerve resection + nerve grafting; Group 4 (n = 15): segmental nerve resection + TEST. Functional recovery was evaluated by walking-track analysis. The sciatic nerves and gastrocnemius muscles were harvested for histologic and quantitative histomorphometric evaluation at 12 weeks. Sciatic functional indices and histomorphometric analyses revealed statistically significant differences between the sham control and the three experimental groups (p < 0.001). The difference between the TEST group and the nerve graft group was not significant; however functional recovery was significantly improved in these two groups, compared to the non-repaired group (p < 0.05). The authors suggest that the TEST provides a suitable conduit between two stumps, eliminates donor-site morbidity, reduces the number of suture sites, fibrosis, and operating time, and might be an alternative to nerve grafting for nerve gap repair.

Prevention of meatal stenosis with W-flap glanuloplasty in hypospadias surgery: a long-term follow-up.

Meatal stenosis is a complication that can occur after hypospadias surgery. Although there are many different surgical techniques that can solve this problem, once it has occurred, meatal stenosis can be difficult to treat. To decrease meatal stenosis risk and to achieve an anatomically placed, aesthetically pleasing meatal opening, a new W flap was designed for glanuloplasty. The authors describe the technique in detail along with long-term results. A total of 356 hypospadias cases were operated using various urethroplasty methods. Independent from the preferred urethroplasty method, the W-flap was used for glanuloplasty in all patients. Patients were followed for 1 to 10 years. Meatal stenosis incidence was 0.8%, and good cosmetic results with a natural-looking, anatomically placed meatus and a well-directed urinary stream during urination were achieved. W-flap glanuloplasty, an addition to reconstructive surgeons' armamentarium, is applicable to most patients. It places the meatus in its appropriate anatomic location, increases the meatal diameter by insetting two flaps, avoids a circular anastomosis, reduces the risk of late contraction, helps to achieve good aesthetic results with good urinary stream, eliminates the need for stents, and reduces meatal stenosis risk overall. It is a good glanuloplasty alternative that can be applied with most hypospadias repair techniques.

Surgical treatment of urethral fistulas following hypospadias repair.

Development of urethral fistulas is one of the most common late complications of hypospadias surgery. A total of 161 male patients who had 186 urethrocutaneous fistulas were first classified according to the fistula classification of Horton and colleagues and then treated with three types of procedures: simple closure, local rotation flaps, or tube graft reconstruction. With initial surgical intervention, 156 of 186 fistulas were treated successfully. The remaining 30 fistulas (16.1%) recurred during the follow-up period. In the recurrent cases, immediate closure was not preferred, and an average of 6 months was waited before considering any additional surgical attempt. Distal cases had a higher failure rate, and the simple closure technique failed to show a success rate as high as local flap or tube graft repair. The high recurrence of distal cases was attributed mainly to the lack of adequate soft tissue adjacent to the fistula, which is vital for safe closure. In addition, the traction effect of erection on the skin and urethra, which is more prominent distally than proximally, is also believed to play an additive role. To increase success, the selection of appropriate treatment modality and customization of techniques for each patient cannot be overemphasized. However, the authors conclude that careful presurgical assessment of the patient, a 6-month delay before any secondary surgical attempt, inversion of the urethral mucosa, avoidance of any overlapping suture lines, urinary diversion proximal to the repair site for 5 to 11 days, and usage of thin, absorbable suture materials are the main criteria that should be met for a satisfactory hypospadias fistula repair.

Assessment of muscle flap sensibility by evoked potentials in the rat.

This study investigated whether the sensory-to-motor reinervation of the muscle flap provides a better sensory recovery of an overlying skin graft. Fifty-four animals were studied in three groups of 18 rats each: group I (control): 1 cm of the gastrocnemius muscle motor nerve was excised and no repair was performed; group II (motor-to-motor repair): the motor nerve of the gastrocnemius flap was transected and repaired; group III (sensory-to-motor repair): the motor nerve of the gastrocnemius muscle and sural nerve were transected and their distal and proximal ends, respectively, were repaired. At follow-up periods of 6, 12, and 24 weeks, evaluation of hair growth, muscle atrophy, and sensory evoked potentials was performed. Somatosensory evoked potentials (SSEP) at 6 weeks in the sensory-to-motor repair (group III) revealed a significant (P < 0. 05) increase (104.4% +/- 22.9) in the relative response of peak-to-peak potentials when compared with group I (46.6% +/- 19) and group II (51.8% +/- 14.0). Muscle flap stimulation was most prominent at 6 weeks in sensory-to-motor reinvervated flaps (group III 133.1% +/- 25.4; group I 84.9% +/- 20.2). In this study, sensory-to-motor nerve repair significantly improved the sensibility of skin flaps at 6 weeks. Denervated flaps presented with 3 months of sensory recovery delay.