Median Cleft Lip.

Complete or partial lip clefts in the midline of the upper lip are defined as median clefts of the upper lip. In 1974, Tessier numbered the craniofacial clefts from 0 to 14 counterclockwise in a study involving 336 patients. Upper lip midline clefts are named Tessier 0 clefts. Despite the diversity in classifications, upper lip midline cleft is rare. Its incidence among cleft patients varies between 0.43% and 0.73%. If the more common forms of cleft lip and palate are not taken into account, the incidence of atypical cleft is estimated at 1/10 5 . A median upper lip cleft can be defined as a cleft that passes vertically through the midline of the upper lip. These clefts occur due to incomplete or complete nondevelopment of the medial nasal prominences. In this study, the authors shared a case diagnosed prenatally and referred to their clinic for cleft lip repair.

Is Histological Evaluation of Reduction Mammaplasty Specimens Worthwhile?

BACKGROUND: Reduction mammaplasty (RM) is one of the most common plastic surgery procedures. Despite its cost, the total number of RM procedures continues to increase every year. OBJECTIVES: The purpose of this study is to review the prevalence of benign and malignant breast lesions among women who live in the Aegean region of Turkey, based on our university hospital's records and to compare our results with those in the literature. METHODS: Seven hundred and thirty-three consecutive female patients who underwent RM between January 2003 and January 2017 in the Department of Plastic, Reconstructive, and Aesthetic Surgery were included in this study. RESULTS: One hundred and sixty-five patients (23.4%) had preoperative breast imaging results. According to the Breast Imaging Reporting and Data System (BIRADS), most of these patients had BI-RADS-2 and BIRADS-1 findings (41.21% and 40%, respectively). Fibrocystic changes were the most common lesions (81.3%). Sixty-eight patients (9.6%) had normal breast tissue on the right side and 34 patients (4.8%) had the same on the left side. Five patients (0.71%) had atypical ductal hyperplasia and no atypical lobular carcinoma. Four patients (0.56%) had occult breast cancer and one patient (0.14%) had benign phyllodes tumor. CONCLUSIONS: RM is a good opportunity to detect proliferative lesions and occult breast cancer. While meeting the patient's aesthetic desires, the plastic surgeon should consider for histopathological evaluation. We suggest that every part of the breast tissue should be sent to pathological examination regardless of the weight of the specimen. Even if health insurance does not cover its cost, patients should be informed about the importance of this process.

The functional results of acute nerve grafting in traumatic sciatic nerve injuries.

BACKGROUND: The sciatic and peroneal nerves are the most frequently injured in lower extremities, followed by tibial and femoral nerves. The aim of this study is to evaluate the functional results of acute nerve grafting in traumatic sciatic nerve injuries. METHODS: A total of 9 patients with sciatic nerve defect were treated with primary nerve grafting. The mean age was 31.7 years. The etiologic factors were gunshot wounds, traffic accident, and penetrating trauma. RESULTS: All of the patients had sciatic nerve defects ranging from 3.4 to 13.6 cm. The follow-up period ranged between 25 and 84 months. The tibial nerve motor function was "good" or "very good" (M3-M4) in 5 patients (55.6%). The plantar flexion was not sufficient for the rest of the patients. The peroneal nerve motor function was also "good" and "very good" in 3 patients (33.3%). CONCLUSION: The functional results of the acute nerve grafting of the sciatic nerve within the first week after the injury are poorer than reported in the related literature. This protocol should only be applied to select patients who have adequate soft tissue coverage and healthy nerve endings.

Necrotising fasciitis in the central part of the body: diagnosis, management and review of the literature.

Necrotising fasciitis (NF) is characterised by rapidly spreading necrosis of the soft tissue and fascia. It is rare but can be fatal when not managed properly. The aim of this study is to evaluate the diagnosis, treatment and results such as mortality, morbidity and reconstructive options of NF localised in the central part of the body. The main goal is to emphasise upon the clinical symptoms for early diagnosis which is the most important factor in saving the lives of these patients. Between January 2000 and December 2010, 30 patients with NF localised in central parts of the body were treated. Six of the patients were female (20%) and the others were male (80%). The mean age was 54·03 years (ranged between 26 and 83 years). The average time from the onset of symptoms to diagnosis was 6 days, ranging from 2 to 11 days. The localisation of NF was perineum in 24 patients (80%); inguinal and thigh region in 5 patients (16·7); and back in 1 patient (3·3%). The hospitalisation time was varying between 17 and 32 days (mean 23 days). Six patients (20%) died and 24 patients (80%) survived. All non-survivors had risk factors and secondary comorbidities such as immunosuppression, chronic cardiac failure, and diabetes with high glucose level. Survivors also underwent repeated debridement operation 2-4 times. Reconstructive procedures were split-thickness skin graft (STSG) in eight patients (33·3%), fasciocutaneous flaps in four patients (16·6%), fasciocutaneous flap + STSG in six patients (25%), scrotal flap + STSG in two patients (6·6%), scrotal flap in two patients (6·6%) and musculocutaneous flap + STSG in one patient (3·3%). There was no major complication such as flap and graft loss, after reconstructive procedures. Early diagnosis of NF may be the lifesaving factor. Amuputation can save the patient's life in the case of NF in the extremities; however, this is not an option for NF in central parts of the body. In these cases, when NF is suspected, early debridement of necrotic tissues should be performed. As soon as the infection and the spread of the necrosis are controlled, reconstruction should be considered.

[Necrotizing fasciitis: diagnosis, treatment and review of the literature]. / Nekrotizan fasiit: Tani, tedavi ve literatürün gözden geçirilmesi.

BACKGROUND: Necrotizing fasciitis (NF) is characterized by rapidly spreading necrosis of the soft tissue and fascia. It is rare, but can be fatal if not managed properly. The aim of this study was to discuss the morbidity and mortality in NF patients in terms of evaluating early diagnostic techniques and reconstructive options. METHODS: Sixty-eight patients (59 male, 9 female; mean age 55.9 years; range 28 to 88 years) with localized NF who were treated between 2000 and 2010 were assessed retrospectively for age, sex, localization, time elapsed between onset of symptoms and diagnosis, predisposing factors, characteristics of tissue defects, isolated microbiological agents, surgical intervention, complications, and mortality rate. RESULTS: In 52 patients (76.4%), comorbidities such as diabetes, obesity, smoking, and corticosteroid use were present. The most common localization was the perineum and inguinal region (n=48, 70.5%). Time elapsed between onset of symptoms and diagnosis was 6.2 days (1-12 days). The mean size of tissue defect after the first debridement procedure was 54.2 cm2 (28-82 cm2). The most common isolated microbiological agents were as follows: Escherichia coli, Enterococci, and Pseudomonas aeruginosa. Polymicrobial infections were encountered in 54 patients (79.4%). The most common reconstructive procedures were fasciocutaneous flap + split-thickness skin grafting (n=39, 57.3%). No major complication was observed; minor complications included wound dehiscence and partial graft loss. The mortality rate was 13.2% (n=9). CONCLUSION: The early diagnosis of NF may be lifesaving. When NF is suspected, early debridement of necrotic tissues should be performed. As soon as the infection and the spread of the necrosis are controlled, reconstruction should be considered.

A successful neurotization of two different muscles using a single intact motor nerve: experimental study on rats.

The development of microsurgical techniques and better understanding of nerve biology has resulted in significant improvement in the results of nerve repair. Some problems are still present. What would be the method of choice if 2 transected nerves were to be coapted and only one neighboring intact nerve was available? We performed neurotization of 2 different muscles by a single intact nerve, using only one nerve graft by reverse end-to-side coaptation that has already been introduced into the literature. We assessed the results histomorphologically and functionally. Twenty-four adult rats were used in the present study and equally divided into 4 groups. Group 1 (n = 6): Control group; Group 2 (n = 6): Unrepaired nerve damage group; Group 3 (n = 6): End-to-end repair group. The peroneal branch of the sciatic nerve was excised to obtain an approximate size of 2 cm-graft, which was subsequently divided into 2 equal pieces to obtain 2 pieces of grafts each 1 cm long. Then, the tibial branch of the sciatic nerve was also cut to produce a nerve defect. End-to-end coaptation was obtained. A "V" shape was obtained. Group 4 (n = 6): Reverse end-to-side repair group. The peroneal branch of the sciatic nerve was excised as a graft approximately 2-cm in length. Subsequently a defect was produced by cutting the tibial branch of the sciatic nerve. Coaptation was performed by suturing the dissected proximal end of the tibial nerve by reverse end-to-side coaptation. A "U" shape resembling a horse shoe was obtained. The success of Group 4 was demonstrated when both peek-to-peek and latency timing of extensor digitorum and gastrocnemius muscles, determined as the target organ, were evaluated. Besides, an equal distribution was observed in Group 4 when number of myelinated (P = 0.596) and unmyelinated (P = 0.936) axons in both legs of grafts were compared with each other. However, myelinated axons were not equally distributed between the legs of the nerve graft in Group 3 (P = 0.027). In conclusion, reverse end-to-side coaptation is a useful technique for 2 different muscle neurotization via a single nerve graft and a single nerve coaptation with a donor nerve.

Supraclavicular artery flap.

Supraclavicular artery-based flaps provide aesthetic and functional coverage for the head and neck region. Fourteen formalin-fixed cadavers were dissected bilaterally, and 28 supraclavicular arteries were evaluated. The origin of the supraclavicular artery was transverse cervical artery in 62.9% and suprascapular artery in 37.1% of the cases. The origin of the artery was at the level of the medial third of the clavicle in 3.7%; 3.7% of the cases were at the junction of medial and middle third of the clavicle, 33.3% at the level of middle third of the clavicle, 11.1% at the junction of middle and lateral thirds, 44.4% at the level of lateral third, and 3.7% at the level of acromioclavicular joint. The mean values of the results were as follows: The diameter of the artery was 1.0 mm at the origin. The distance of the origin of the artery from sternoclavicular joint and from the upper border of the clavicle was 76.4 and 22.2 mm, respectively. The average length of the artery was 70.8 mm. In all dissections, the artery was deep to the platysma muscle. Forty-one percent of supraclavicular arteries accompanied the middle supraclavicular nerve, whereas 59% of the arteries run with lateral supraclavicular nerve. The supraclavicular artery had a parallel course to the 2 horizontal imaginary lines passing from the coracoid process and acromion in 63% of the cases; 18.5% of the arteries were oblique, and 18.5% were vertical to the imaginary lines. The venae comitantes were double in all dissections.

Surgical management of hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, relapsing inflammatory disease of skin, characterized by recurrent draining sinuses and abscesses, predominantly in skin folds carrying terminal hairs and apocrine glands. METHOD: This study reviewed 54 sites in 27 patients with moderate to extensive chronic inflammatory skin lesions treated surgically in our hospital from 2004 through 2009, with a follow-up of at least 6 months. RESULT: A total number of 54 operative procedures were performed during the study period with 42% (23 sites) involving the axilla, 20% (11 sites) involving the gluteal area, %24 (13 sites) involving the perineal area and 12% (7 sites) involving the inguinal region. CONCLUSION: Conservative treatment methods have little or no effects especially on gluteal, perineal/perianal, axillary hidradenitis suppurativa. The morbidity associated with the established form of this disease is significant, and the only successful treatment is wide surgical excision.

A comparison of vascularized fibular flap and iliac crest flap for mandibular reconstruction.

Segmental mandibular defects, which are caused either by ablative surgery or trauma, are usually accompanied by different degrees of skin, soft tissue or mucosa losses. The reconstruction of such defects requires complicated surgical procedures. An ideal mandibular reconstruction method must support the insertion osseointegrated dental implants which is necessary for total oral rehabilitation. The soft tissue defect should also be reconstructed if it accompanies the bony defect. We performed 37 mandibular reconstructions using either vascularized iliac crest flap or fibula flap. Sixteen of 24 patients who underwent mandibular reconstruction using iliac crest flap, and 3 of 13 patients who has been reconstructed with fibula flaps, had mandibular defects involving skin and/or mucosa. Both techniques were compared regarding patients records such as hospital stay, operation time, defect size, etiopathogenesis, skin paddle, blood transfusion, and complication rates. Self-assessment questionnaires were also used to evaluate aesthetic and functional results. When 2 different mandibular reconstruction techniques are compared regarding patient records, the complication rate of fibula flap was less than the iliac crest flap. Functional and aesthetic results also showed that oral continence, social activities, and facial appearance rates of fibula flap were superior to iliac crest flap. Lower complication rates of fibula flap group may be associated with patients' higher satisfaction rate. Both flaps are commonly used in mandibular reconstruction, however, many parameters including defect localization, defect size, presence of soft tissue defect should be considered.

Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction.

Various alloplastic and autogenous materials have been used for dorsal nasal augmentation. Bone and cartilage autografts commonly are used. We used rib cartilage graft for dorsal nasal augmentation. The aim of this study was to investigate the long-term outcomes and patient satisfaction of dorsal nasal augmentation with rib cartilage grafts. Thirty-eight patients who had been operated on for dorsal nasal augmentation with rib cartilage graft were included in this study. Operation times, postoperative complications, and revision surgery were investigated by using hospital records. Anthropometric measurements were used for determining the resorption rate of cartilage graft. A questionnaire was used for the evaluation of long-term patient satisfaction. Evaluation of the patients' records showed that average operation time was 116 minutes and there were no complications such aspleural damage. The mean follow-up period was 27.4 months. Nine patients required secondary nasal surgery, including soft tissue augmentation (n = 1), nasal tip revision (n = 3), and reshaping the cartilage graft (n = 5). Long-term anthropometric measurements, comparing preoperative and postoperative values, documented increases in both tip projection (4.2%) and nasal length (1.2%) and an increase in nasolabial angle of 8.2 degrees . Eighty-one percent of the patients who answered the questionnaire rated the nasal size as normal. Nasal symmetry and nasal shape were good in 75% and 66% of the patients, respectively. Results of the rib cartilage grafts that are used for dorsal nasal augmentation are satisfactory for the patients and resorption rates are not high enough to change the shape of the nose.

Total vaginal reconstruction with combined 'Split Labia Minora Flaps' and full-thickness skin grafts.

PURPOSE: Vaginal reconstruction with split-thickness skin grafts is the most common method for total vaginal reconstruction. Although it has disadvantages like contraction of the graft, foreshortening, donor site morbidity and long-lasting periods of vaginal standing; its easy surgical technique makes it popular. A new method using split labia minora (LM) flaps and full-thickness skin graft is discussed in this study. METHOD: A 19-year-old female was presented with amenorrhea. A total absence of vagina was present and the patient underwent a total vaginal reconstruction for possible sexual intercourse. RESULTS: We observed no contraction and no foreshortening with a patent vaginal cavity up to 11 cm and 4.5 cm width. The need for continuous standing period was as short as 4 weeks and for intermittent standing up to 4 months. Sexual intercourse was encouraged after 4 weeks. During sexual intercourse no external lubrication was reported to be needed. There was no need for further reconstructive intervention. CONCLUSION: Vaginal reconstruction in congenital vaginal agenesis with split LM flaps and full-thickness skin grafts is a simple and effective method, which shortens the standing period and decreases the contraction in neovagina. Total vaginal reconstruction with split LM flaps could also be possible; to achieve this goal, expansion of LM flaps could be a further alternative.

Repair of fractures of the orbital floor with porous polyethylene implants.

Our main aim was to evaluate the long-term results after reconstruction of the orbital floor with porous polyethylene implants. Twenty-six patients with fractures of the orbital floor were included in the study. The main cause of fractures was road crashes. They also complained of enophthalmos (n=19), diplopia (n=21), limited extrinsic ocular motility (n=17), impairment of the infraorbital nerve (n=18), and hypoglobus (n=9). All the fractures were reconstructed with thin and ultra-thin porous polyethylene sheets. No implants extruded and there were no signs of inflammatory reaction against the porous polyethylene. The symptoms were treated in 14 patients with enophthalmos, 18 with diplopia, 16 with limited extrinsic ocular motility, 14 with impairment of the infraorbital nerve and 8 with hypoglobus. Postoperative infections in four patients were treated with systemic antibiotics. Persistent ectropion was present in two patients. Porous polyethylene sheets are reliable, safe and effective implants and may be used for reconstruction of the orbital floor fracture with no donor site morbidity or need to fix implant.

Surgical management of ameloblastoma in the mandible: Segmental mandibulectomy and immediate reconstruction with free fibula or deep circumflex iliac artery flap (evaluation of the long-term esthetic and functional results).

PURPOSE: Ameloblastoma is responsible for 1% of all the oral and maxillomandibular cysts and tumors. It is odontogenic in origin and benign in nature but it has a high percentage of local recurrence rate and possible malignant development when treated inadequately. With the advancement of craniofacial surgical techniques, use of free flaps for mandibular reconstruction, and dental rehabilitation (such as osseointegration), the segmental mandibulectomy and immediate reconstruction with free flaps are beginning to be used more effectively for the treatment of the mandibular ameloblastoma. The aim of this article is to evaluate the clinical results of the patients with mandibular ameloblastoma who were treated with segmental mandibulectomy and immediate reconstruction with free flaps. PATIENTS AND METHODS: We present 11 patients who had segmental mandibulectomy and immediate reconstruction with free deep circumflex iliac artery or fibular flap for treatment of mandibular ameloblastoma. The average age of the patients was 25.4 years (range, 18-38 years). The patients were followed up for a mean of 29.3 months (range, 17-38 months). The functional and esthetic results were also evaluated by using a questionnaire in the long term. The questionnaire consisted of questions addressing oral continence, diet, social activities, speech, and facial appearance. RESULTS: All flaps survived totally. Recurrence was not detected during the follow-up period. It was found that all patients had good esthetic and functional results after immediate reconstruction. The social activities of patients also were not affected after treatment. CONCLUSIONS: We experienced that segmental mandibulectomy with safe borders and immediate reconstruction with free fibula flap or deep circumflex iliac artery (DCIA) flap is an ideal treatment method for mandibular ameloblastoma. The functional and esthetic results are also detected as very satisfactory for the patients.

Total lower eyelid reconstruction using paranasal flap.

The main aim of this study is to evaluate the advantages, disadvantages, and aesthetic results of the total lower eyelid reconstruction with paranasal flap. The other reconstruction methods are also revisited.Ten patients, who were operated for the reconstruction of total lower eyelid defects between November, 1999 and April, 2005 in our department were included in this study. The total lower eyelid defects of all patients were reconstructed using paranasal flap for anterior lamella and chondromucosal, chondrocutaneous or mucosal graft for posterior lamella. Follow-up time was ranged between 3-35 months. The advantages, disadvantages and complications were defined and aesthetic results of the patients were also evaluated by using a questionnaire which was filled by patients at third month after reconstruction. All flaps and grafts survived, partial or total necrosis was not encountered but one patient with ectropion had a secondary reconstructive procedure. The aesthetic results of the patients were also satisfactory. The paranasal flap is very reliable and safe method for total lower eyelid reconstruction.

Management of close-range, high-energy shotgun and rifle wounds to the face.

Close-range, high-energy shotgun wounds of the face are life-threatening and devastating traumas of the face. Suicidal attempts are the main reason in the great majority of the patients in civilian life. There is no consensus on the timing of reconstruction for bone and soft tissue defects resulting from high-energy shotgun wounds. The conventional method is primary repair as soon as possible and serial debridements and definitive reconstruction in the delayed stage. An alternative to this approach is the immediate definitive surgical reconstruction of the patient during the first operation for acute management of trauma. We had 15 patients with close-range, high-energy shotgun wounds in 10 years. Six of 15 patients referred to our center for definitive reconstruction after the acute management of the patients were performed in another center and the rest were all admitted in the acute period. Either conventional approach with delayed reconstruction for 10 patients or immediate definitive surgical reconstruction for 5 patients was used. Immediate reconstruction eliminated disadvantages of the conventional method such as high infection and scarring rate and deformities resulting from contraction of tissues. The emotional conditions of the patients were evaluated and major depression signs were determined. Functional evaluation showed that there was great correlation between facial appearance after reconstruction and social activity level.

Question mark ear deformity and a modified surgical correction method: a case report.

Question mark ear (Cosman ear) deformity, a rare congenital malformation, is characterized by a cleft between the helix and the ear lobe and marked prominence of the auricles. Although the features of question mark ear deformity are well described in the literature, there is no definitive surgical technique for repair of this deformity, Several surgical methods have been introduced for the correction of the deformity. These techniques mainly provide for repair of the cleft between the helix and ear lobe. However, marked prominence of the upper auricle usually is also present with the cleft. We modified the surgical technique to correct the cleft and the upper prominence at the same time. With this procedure, the cleft is exposed by raising a vertical cutaneous flap based on the cleft on the posterior side of the ear, After anterior scoring to form the antihelix and cleft repair using an ipsilateral conchal cartilage graft, the cutaneous flap is used to cover the cartilage graft and the flap donor site is closed primarily to facilitate restoration of the antihelix. The authors report on a patient with Cosman ear and introduce their modified technique that can be used for repair of the cleft between the helix and ear lobe and the prominence of the upper helix in the same procedure.

Evaluation of results from reduction mammaplasty: relief of symptoms and patient satisfaction.

Reduction mammoplasty is one of the most common operations performed in plastic surgery clinics. Although patients present with functional symptoms, the aim of treatment usually is obtaining aesthetic satisfaction. This retrospective study evaluated charts and operation notes of patients and a self-assessment questionnaire. A detailed questionnaire form was sent to 121 patients who had undergone reduction mammaplasty at the Dokuz Eylul University Medical Faculty Plastic, Reconstructive, and Aesthetic Surgery Clinic between 1991 and 2001. The questionnaire asked the subjects about pre- and postoperative, physical, and psychosocial symptoms, as well as operative satisfaction. The results were evaluated with respect to different techniques. The findings showed that reduction mammaplasty remains a very satisfying procedure for most of the patients undergoing this operation, as indicated by the high rate of patient satisfaction. The limited number of studies in this area and the lack of groups conducting such work in our society indicates the importance of similar study.

Repair of cartilage defects with periosteal grafts.

Alternative sources for repair of cartilage defects are limited and donor sites are associated with morbidity. It is known that cartilage development from periosteal grafts is possible. Various factors have been found positively to affect this process in experimental settings. However, all of these studies were limited to joint cartilage. We conducted an experimental study in rabbits for the investigation of the elastic cartilage regeneration from perichondrial and periosteal grafts together with the effects of hyaluronan on this process. 1 x 1 cm(2) cartilage defects were created on the elastic ear cartilage of rabbits. Four experimental groups with 18 ears in each group were created: Group 1 (repair with perichondrium graft), group 2 (repair with periosteum graft), group 3 (repair with periosteum graft+hyaluronan), group 4 (defect-only control group). Macroscopic and microscopic evaluations were done on the 4th, 8th and 12th weeks. Cellular morphology of the regenerated cartilage and its integration and similarity with adjacent cartilage were evaluated. Cartilage regeneration groups 1, 2 and 3 were found to be statistically different from the control group. There was not a significant difference between groups 1 and 2 or 2 and 3. There is no significant difference between perichondrial and periosteal grafts in cartilage regeneration, and hyaluronan has no beneficial effect on this process.

Prevention of peritendinous adhesions following flexor tendon injury with seprafilm.

Peritendinous adhesions are the most important complication of flexor tendon injury. In this study, Seprafilm was used for the prevention of peritendinous adhesions following flexor tendon repair. Seprafilm Bioresorbable Membrane (Genzyme Corporation, Cambridge, MA) contains sodium hyaluronate and carboxymethyl cellulose. Thirty New Zealand white male rabbits were divided equally into 3 groups. In all groups, the deep flexor tendon of the third finger of the left back foot was cut and repaired by Kessler-Tajima suture technique. In the first study group following tendon repair, Seprafilm was wrapped around the repaired tendon. In the second study group, sodium hyaluronate gel was injected to the operation field after tendon repair. In the control group, no external material was applied to the field. The study groups had better range of motion. Histopathologically, study groups had less adhesions compared with the control groups. As a result, it was concluded that in rabbit the peritendinous adhesions following flexor tendon repairs could be lowered with Seprafilm and hyaluronic acid.