Single-session repair of multiple pressure ulcers in non-ambulatory patients.

OBJECTIVE: Pressure ulcers (PUs) are highly prevalent and challenging wounds. In this study, patients with either tetraplegia or paraplegia, all of whom had multiple grade 4 PUs and who underwent single-session surgical treatment were included. In order to increase the mobility of the musculocutaneous flap, the gluteus maximus muscle, which cannot be used by immobile patients, was detached and inserted into the flap. METHOD: This was a retrospective case series and all PUs were reconstructed within the same surgical session. RESULTS: A total of nine patients participated in the study, all of whom were male. Mean age was 33 years (range: 20-42 years). Mean follow-up period was 14.3 months (range: 9-24 months). All patients had a successful single-session repair of all PUs. Total or partial flap losses were not observed. Mean and total number of reconstructed PUs were 2.55 and 23, respectively. The mean area of reconstructed open wounds per patient was 174.6cm2 and the mean operation duration was 253 minutes. The level of blood loss was acceptable as the decrease in haemoglobin levels was not more than 2g/dl for each patient. CONCLUSION: Multiple PUs can be repaired in one session using gluteus maximus musculocutaneous flaps in immobile patients. Based on the fact that the gluteus maximus is an essential muscle for ambulation, our approach can only be used in the treatment of patients with irreversible paraplegia or tetraplegia. When all prerequsities are met, the amount of blood loss and operation duration are acceptable, and returning the patient to a wound-free state can be achieved more quickly compared to multi-session repairs. Air-fluidised beds are vital tools for accomplishing single session repairs of multiple PUs. The data shows that the approach is safe and can be used in patients with multiple PUs.

A Wise Surgical Approach for Reconstruction of Postburn Axillary Contractures and Versatility of Perforator Flaps.

Postburn axillary adduction contractures should essentially be released for adequate shoulder function. Many methods have been described for this purpose. However, use of perforator flaps prevents harm to the underlying muscle and provides thin, pliable skin flaps. Despite the major advantages offered by perforator flaps, certain shortcomings of perforator flap surgery restrict their widespread use by inexperienced surgeons, including anatomic variations of perforator vessels. In order to rule out these shortcomings, we devised a new surgical approach with an initial incision that provides access to possible perforator systems on the dorsolateral thoracic area. The approach can easily be converted to a fasciocutaneous transposition flap when attempts for identification of a proper perforator fail. Nevertheless, a proper perforator can easily be reached through the exposure provided by this initial incision. With the intention of using perforator-based flap for reconstruction, we used this surgical approach for coverage in 14 cases of postburn axillary contractures. In 3 cases, conversions of the initial incision to local transposition flap (parascapular flap) were required. There was only 2 tip necrosis observed, which healed with secondary intention. Our current surgical approach may offer taking the advantages of using a true perforator flap for reconstruction while avoiding a second stress on the patient when an operative plan for perforator flap harvest fails.

Sutureless microvascular anastomosis with the aid of heparin loaded poloxamer 407.

BACKGROUND: Anastomosis with tissue adhesives is an alternative method for conventional anastomosis. However, this method has several technical challenges. It requires the use of suture to prevent leakage into lumen and precise application onto all surfaces of the anastomosis site. To solve these problems, poloxamer 407 (P 407) was previously used as a stent. In this study, we made heparinized P 407 (h-P 407) as a new formula. We aimed to successfully use h-P 407 as a stent in sutureless anastomosis in a rat abdominal aorta model. METHODS: Sixty Sprague-Dawley rats were used. In the first group, end-to-end anastomoses were performed with suture; in the second and third groups, sutureless anastomoses were performed with 2-octyl cyanoacrylate. As an intraluminal stent, P 407 was used in the second group, and h-P 407 was used in the third group. Anastomosis time was measured. Lumen width, intimal hyperplasia, and foreign body reaction were assessed histologically. Velocity flow rates and vessel diameters were measured radiologically. Burst strength was measured, and the results were statistically evaluated. RESULTS: Sutureless anastomosis was more rapid than conventional anastomosis. Lumen width was narrower in the suture group. Inflammation and foreign body reaction were more severe in the suture group. There was no radiologic and biomechanical difference between the groups. We found that intimal hyperplasia was less in h-P 407 than in P 407. CONCLUSION: h-P407 can be successfully used as an intraluminal stent for sutureless microvascular anastomosis with tissue adhesives.

A new experimental burn model with an infrared heater.

BACKGROUND: This study was undertaken to develop new experimental burn injury model using conventional infrared heaters. METHODS: 21 Sprague-Dawley rats were divided into 3 groups. Portion of dorsal area was exposed to infrared radiation from distance of 50 cm to create burn injury. Length of exposure to heat for Group 1 was 5 minutes; Group 2 was exposed for 7½ minutes, and Group 3 was exposed for 10 minutes. Macroscopic and histopathological evaluations were utilized to demonstrate depth and characteristics of injury. RESULTS: There was no burn injury in first group. Group 2 developed partial thickness burn, and result was full thickness burn injury in Group 3. In Groups 2 and 3 there was statistically significant difference in dermal collagen denaturation. Dermal injury depth was statistically significantly higher in Group 3 compared to Group 2. CONCLUSION: New experimental burn injury model is described using conventional infrared heaters. Standard variables pertaining to model were defined to produce burn injuries at predictable depth: 10 minutes of exposure from 50 cm distance for full thickness burn, and 7½ minutes of exposure from the same distance for partial thickness injury.

The Reverse Fasciocutaneous ALT Flap Harvested From Deeply Wounded and Scarred Area for Reconstruction of the Knee: A Case Report.

Because of limited flap alternatives, soft tissue reconstruction over the knee is a challenging problem for reconstructive surgeons. When accompanied with surrounding tissue damage in major injuries, local flap alternatives are not available and reconstruction is more difficult. In this report, we present the first case in the literature of a patient who had reconstruction by the reverse fasciocutaneous anterolateral thigh (ALT) flap harvested from a deeply wounded and scarred area for soft tissue defect of knee region. It was shown that the ALT flap can be harvested from deeply wounded and scarred thigh and without any major complication and debulking procedure and that ideal cosmetic and functional results could be achieved.

Staged repair of severe open abdomens due to high-energy gunshot injuries with early vacuum pack and delayed tissue expansion and dual-sided meshes.

BACKGROUND: Open abdomen is a salvage procedure that prevents catastrophes after severe intraabdominal traumas. However, following this life saving attempt, it is mostly not feasible to close the abdomen immediately after the recovery of intraabdominal injuries. Consequently, a staged reconstruction is required, and the first stage is usually a temporary closing approach. At the end of this stage, resulting giant "ventral hernia" is a burden for both the patient and the surgeon. Therefore a permanent repair is subsequently needed. Although there are many treatment modalities described for this goal, etiologies like high-energy gunshots may cause an exactly nuisance scene which can limit treatment options and reduce final success. Herein, it was the objective of this study to present our staged protocol to restore the abdominal wall defect and strategy for optimizing the results in such conundrum cases. METHODS: Treatment was performed on nine male patients suffering from severe open abdomen due to high-energy gunshot injury. In all patients, temporary closure was provided by negative pressure wound treatment applied directly to the viscera and followed by skin grafting. Late permanent closure was performed with the lamination of expanded abdominal skin and dual-sided meshes. RESULTS: The follow-up period ranged between 24 months to 4.5 years (mean, 3 years). During this period, no recurrence of ventral hernia, enteric fistula formation, abdominal infection and seroma formation was observed in any patient. CONCLUSION: In this study, NPWT, tissue expansion and dual-sided mesh were used together as a staged procedure for optimizing the results in the clinical scenario of an open abdomen due to high-energy gunshot wound. Results were highly satisfactory for patients and acceptable aesthetically.

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.

Reconstruction of the one-digit foot with an osteocutaneous fibula flap: a case report.

The decision to amputate or reconstruct after high-energy foot injuries is controversial. A 25-year-old male patient was admitted to our clinic with a complex injury to his left foot sustained during a mine explosion, and the second to fifth digits and metatarsals of the left foot had been traumatically amputated before admission to our facility. The complex left foot defect was reconstructed with an osteocutaneous fibula flap during a single session. An osteotomy was performed on the bone segment of the flap, and both lateral longitudinal and transverse arches were repaired. Both aesthetic and functional outcomes were very satisfactory, including independent ambulation, light jogging, and full performance of activities of daily living without limitation. Many factors, including comorbidities, should be considered during the decision-making process of amputating or reconstructing complex foot injuries.

An extraordinary case of axillary contracture: trapped healthy skin and its adnexes under contracted scar.

Although striking improvements have been achieved in overall management of burn injury, postburn contractures are still an ongoing challenge to burn surgeons. Axillary adduction contracture is one of the most common types of these disabling postburn complications that usually result from suboptimal treatment after acute burns. An unusual and complicated case of axillary contracture in which the unburned, healthy axillary dome skin was trapped as a cystic mass under the scarred area was reconstructed by transfer of a big (17×13-cm) thoracodorsal artery perforator flap after contracture release. The result was satisfactory in terms of function and acceptable cosmetically. The underlying reasons for the inadequate treatment the patient received after surviving a severe electrical injury were discussed.

The effect of recombinant hirudin on rabbit ear flaps with venous insufficiency.

The effect of recombinant hirudin, which is the most powerful antithrombotic agent, on flaps with venous insufficiency was investigated. Oedema and congestion are frequent on flaps, causing necrosis unpredictably. Venous insufficiency and thrombosis are experimentally and clinically more frequent than arterial occlusion. Twenty-one adult New Zealand rabbits were used in this study. Skin flaps (3 × 6 cm) were elevated on a 1-cm-wide pedicle on rabbit ears. The artery, nerve, and vein were exposed and examined with the aid of a surgical microscope. Venous insufficiency was established by cutting the vein and nerve. In the control group, no additional surgical or medical procedures were performed and the ear flap was inset to its original location. Subcutaneous low molecular weight heparin (LMWH; 320 IU/kg) was administered to a second group of rabbits after the same surgery, and recombinant hirudin (2 µg) was administered via the pedicle artery 5 minutes after the vein and nerve were bound and cut in a third group of rabbits. Compared with control and LMWH groups on day 3 and 7, the hirudin-treated group had less hair loss, lower oedema scores and less haematoma formation. Furthermore, a lower size of necrotic areas and an increase in the circulating area on day 7 was found in the hirudin-treated group. In addition, angiography revealed new vessel development (neovascularisation) only in the hirudin group. On histologic sections, hirudin-treated animals had lower oedema, inflammation and congestion scores than animals in the other two groups. Thus, when administered into the ear flap through the pedicle as a pure recombinant preparation, hirudin increased flap survival by its antithrombotic effects and by accelerating neoangiogenesis. Recombinant hirudin may be used in clinical practice to treat flaps with venous problems and to increase survival rates.

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.

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.

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.

Giant cell tumour of the flexor tendon sheath of the foot.

Giant cell tumour of tendon sheath (GCTTS) is a benign, soft-tissue tumour arising from synovial cells of tendon sheaths. Because of the high incidence of recurrence, radical surgical excision is the treatment of choice. Presented here is a rare case of this lesion originating from flexor tendon sheaths of the foot. A 40-year-old Russian white female presented to the clinic with a slightly painful soft tissue mass in her right foot along the medial aspect of her ankle. She gave a one-year history of the mass and was concerned about increasing size, pain, and plantar numbness as well as limitation in her movements to some extent. Interpretation of the magnetic resonance imaging failed to include giant cell tumours in the preoperative differential diagnosis. Considering the proximity of the tumour to important anatomic structures, less radical but grossly complete excision was employed, followed by appropriate periodic re-evaluation. Pedal involvement of GCTTS is rare with a reported predilection for dorsal and lateral localisations around the ankle. Our case presents an unusual occurrence of this tumour with medial localisation of the lesion in the foot, extending through the tarsal tunnel.

Correction of thumb deformities after burn: versatility of first dorsal metacarpal artery flap.

In the management of a debilitated burned hand due to contractures, thumb reconstruction constitutes the most crucial part for a beneficial functional outcome. Among the limited local flap alternatives for the thumb, the first dorsal metacarpal artery flap, harvested from the dorsal aspect of the index finger can provide elastic, durable and sensate coverage for soft tissue defects after contracture release. In a 3-year period, neurovascular island first dorsal metacarpal artery flap was used in 14 patients suffering thumb deformities. The time elapsed after the underlying injury until reconstruction ranged from 5 months to 17 years. Follow-up revealed that all deformities were successfully treated with satisfactory functional recovery and cosmetic results. Donor site morbidity was minimal with an acceptable scar on the dorsum of the index finger and adequate tendon gliding without producing extension deficit. Our experience with management of deformities involving the thumb and/or adjacent thenar area revealed that the first dorsal metacarpal artery flap is a reliable local neurovascular island flap option, offering acceptable functional and cosmetic outcomes in respect to sensation, elasticity, durability and skin-match.

Congenital double lip: review of 5 cases.

Congenital double lip is rare and usually involves the upper lip. Apart from a deformity that interferes with speech and mastication, operation may be indicated for cosmetic reasons. We have operated on five patients with double lip deformities for cosmetic reasons. Although a midline constriction band between two mucosal bulges is thought to be a constant feature, four of our five cases did not have a midline constriction. We used an elliptical excision of the mucosal excess in the four patients. The one with central constriction had an elliptical excision on each side, combined with a vertical midline Z-plasty to release the central constriction. Satisfactory aesthetic results were achieved in all patients.

A 2-year-old girl with Stevens--Johnson syndrome/toxic epidermal necrolysis treated with intravenous immunoglobulin.

Toxic epidermal necrolysis and Stevens-Johnson syndrome are severe skin reactions, usually to drugs, associated with a widespread destruction of the epidermis. Widespread purpuric macules and epidermal detachment of less than 10% of the body surface is indicative of Stevens-Johnson syndrome, whereas epidermal detachment between 10% and 30% is called Stevens-Johnson-toxic epidermal necrolysis overlap. Epidermal detachment involving more than 30% of the total body surface is designated as toxic epidermal necrolysis. These generalized reactions are known to occur in association with various drugs. Treatment is primarily supportive care, and there are no specific therapy regimens. Therapeutic modalities such as corticosteroids, cyclosporin, thalidomide, cyclophosphamide, and plasmapheresis, usually based on a symptomatic approach, have been tried in single patients or in small series. Intravenous immunoglobulin has recently been shown to provide rapid improvement in all three of these skin reactions. We report a 2-year-old girl who developed Stevens-Johnson syndrome-toxic epidermal necrolysis overlap after receiving ampicillin-sulbactam for an upper respiratory tract infection. She was treated successfully with a 4-day course of intravenous immunoglobulin.

A custom-made distraction device for experimental mandibular distraction osteogenesis.

Distraction osteogenesis has recently become popular in craniofacial reconstruction, after it was first described for long bones. Despite the widespread clinical use of this technique, currently, lack of an ideal experimental model for small animals hampers investigations focused on its molecular basis, which warrants further elucidation. The authors developed a new device for distraction of the rat mandible and, to asses its effectiveness, practiced on 30 animals assigned to either an acute 3-mm distraction group (n = 7) or a gradual distraction group (0.25 mm twice a day for 6 days; n = 23). The authors applied the devices to a localization that allowed them to perform the ostomies posterior to the molar teeth. Because of a U-shaped plate that the authors used for posterior pin fixation, their device maintained its stability until the end of the study, despite the delicate anatomy of the bone at the posterior part of the mandible. Additionally, the authors described a practical and easy method of transient mandibular stabilization method that facilitates the manipulations while the mouth is open for safer airway control during surgery. This new nutrition technique with enteral feeding solution solved the problem of progressive weight loss after surgery. Application of the device was easy and practical, without demanding complex manipulations. The authors did not observe any device dislodgement or a high rate of accidental fractures during the manipulations. They demonstrated that the device works properly and is able to create ossified regenerate bones that fill the entire distraction gap, which can be used for various investigations during distraction osteogenesis.

An unusual burn injury caused by a car battery.

In a car battery accident, a 21-year old man sustained a band of deep burn involving the dorsoradial aspect of the wrist. He was treated by excision and grafting on the third day after injury. A metal watchstrap that the patient was wearing, with evidence of the arching phenomenon on it, short-circuited the battery of the vehicle. Although the underlying etiology that triggered the events leading to thermal injury was an electrical accident, the current did not pass through any part of the patient's body, as what happens in an electrical injury. In our current understanding, the pathophysiology of electrical injury dictates the transmission of current through living tissues, leading to a specific type of tissue damage that should be distinguishable from the type that results from a usual thermal injury, as it happened in our case.