Comparison of Dorsal Intercostal Artery Perforator Propeller Flaps and Bilateral Rotation Flaps in Reconstruction of Myelomeningocele Defects.

AIM: To compare the complications and surgical outcomes between bilateral rotation flaps and dorsal intercostal artery perforator (DICAP) flaps in the soft tissue reconstruction of myelomeningocele defects. MATERIAL AND METHODS: Between January 2005 and February 2017, we studied 47 patients who underwent reconstruction of myelomeningocele defects. Patient demographics, operative data, and postoperative data were reviewed retrospectively and are included in the study. RESULTS: We found no statistically significant differences in patient demographics and surgical complications between these two groups; this may be due to small sample size. With regard to complications-partial flap necrosis, cerebrospinal fluid (CSF) leakage, necessity for reoperation, and wound infection-DICAP propeller flaps were clinically superior to rotation flaps. Partial flap necrosis was associated with CSF leakage and wound infection, and CSF leakage was associated with wound dehiscence. CONCLUSION: Although surgical outcomes obtained with DICAP propeller flaps were clinically superior to those obtained with rotation flaps, there was no statistically significant difference between the two patient groups. A well-designed comparative study with adequate sample size is needed. Nonetheless, we suggest using DICAP propeller flaps for reconstruction of large myelomeningocele defects.

Reconstruction of a Marjolin Ulcer Defect of the Scalp Invading Brain and Causing Brain Abscess Formation Using Free Latissimus Dorsi Flap.

Marjolin ulcers are known as aggressive malignant tumors that mostly arise over chronic wounds and cutaneous scars. Brain abscess is a serious medical condition that requires surgical drainage along with antibiotic treatment. Here, we report a case with a Marjolin ulcer located over the right parietal bone with intracranial abscess formation along with tumor invasion into brain parenchyma. This patient was a 64-year-old man and had a 4 × 4 cm open wound on his scalp from which a purulent discharge was coming. This wound required surgical excision with security margins, resection of bone, evacuation of the cystic cavity, and excision of the walls of the cystic cavity, which were invaded by the tumor. Duraplasty and reconstruction of the defect with a free lattisimus dorsi flap are performed. To the best of our knowledge, the case reported here is unique because of the formation of brain abscess in the background of a long-lasting Marjolin ulcer invading brain parenchyma. It must be remembered that on the background of cutaneous scars located over the scalp, a Marjolin ulcer may develop, and if left untreated, tumor cells may invade even the brain parenchyma. Long-term asymptomatic brain infections may also accompany the given scenario, and complicate differential diagnosis.

Should the Macular Lesions Around Spinal Dysraphism Be Excised? Analysis of Macular Lesions Accompanying Spinal Dysraphism.

AIM: Whether the macular lesions associated with spinal dysraphism should be preserved is controversial. This area is usually excised during reconstruction. This study aims to characterize the macular lesions associated with spinal dysraphism and to determine the outcomes of cases in which macular lesions are not excised. MATERIAL AND METHODS: The patient cohort comprised 17 patients with spinal dysraphism who were treated at Mersin University Hospital from 2005 through 2007. Blood and tissue samples were obtained from these patients. RESULTS: Electron microscopy results of tissue samples obtained from macular lesions are not consistent with those of hemangiomas. Increased numbers of vessels and significant dilatation was noted upon examination by light microscopy. The number of mast cell numbers, blood estradiol levels, expression of tissue inhibitor matrix metalloproteinase-1 (TIMP-1) and vascular endothelial growth factor (VEGF), and dermal collagen fiber diameter were within normal range. Estrogen receptor-ß was not expressed. The number of endothelial cells expressing von-Willebrand factor was higher in the macular lesions. CONCLUSION: The characteristics of macular lesions associated with spinal dysraphism are consistent with those of capillary malformations. We believe that the preservation of these macular lesions during soft tissue reconstruction of spinal dysraphism defects, either by mobilization on a flap or primary closure, does not compromise the viability of the macular region. By preserving these macular lesions, the creation of larger defects during excision is avoided.

Reliability of extended dorsal intercostal artery perforator propeller flaps for reconstruction of large myelomeningocele defects.

Reconstruction of large myelomeningocele defects using extended (elongated beyond the lateral margin of the latissimus dorsi muscle) dorsal intercostal artery perforator (DICAP) propeller flaps is not recommended by previous studies. However, to provide tension-free and successful closure of a defect, the DICAP propeller flaps must sometimes be elongated beyond this margin. Our experience and results in this issue are discussed. In this article, reconstruction of 11 consecutive cases, with large myelomeningocele defects in which standard DICAP propeller flaps were incapable to close the defect, was achieved using extended DICAP propeller flaps between June 2013 and November 2015. At least two reliable perforators of the neighboring intervertebral spaces are included to supply the flap. Intramuscular dissection of perforators is performed to free the perforators from the surrounding muscle and to gain pedicle length as much as possible to prevent twisting and vascular compromise. All the flaps survived completely except for one patient who had superficial skin necrosis on the most distal part of the flap and had severe accompanying systemic disorders and died on postoperative 14th day. In 7 of 11 patients, venous congestion was noted, which resolved spontaneously. No hematoma or seroma formation was observed during the postoperative follow-up period. Dissection of multiple DICAPs supplying flaps enable us to harvest larger DICAP flaps possibly by providing better arterial supply and venous drainage. We use microsurgical instruments and 4.3× loupe magnification for pedicle dissection in this newborn population. This study shows the reliability of extended DICAP propeller flaps when multiple perforators at sixth or more cranial adjacent intercostal spaces are included in DICAP propeller flaps.

Nasal Dorsum Management Using Fragmented Cartilage Grafts.

Thinness of nasal dorsum skin and subcutaneous tissue underlying nasal dorsal skin are the major factors related to the visibility of small irregularities. Here, the authors discuss the use of bare fragmented cartilage grafts in managing nasal dorsum and the results obtained.Eight hundred fifty-six patients were operated for rhinoplasty between September 2009 and September 2014. Fragmented cartilage grafting over the nasal dorsum was performed in 781 of 856 patients. In total, 214 patients who were followed up regularly were evaluated. Nasal dorsum management of 182 out of 214 patients was performed as is described here and is included in this study. The authors fragmented the cartilage grafts with Kocher clamp until the fragmented cartilages do not exhibit resistance, which are then placed over the nasal dorsum and can be shaped easily by external manouevers.Follow-up period ranged from 6 to 36 months. There was no seroma formation, infection, or abscess formation during the postoperative follow-up period. Four patients required a secondary operation for nasal dorsum management. The irregularity was corrected by simple rasping. The rest of the patients were satisfied with their nasal dorsum appearance. Nasal dorsum management with fragmented crushed cartilages showed durable results during the follow-up period.The authors use fragmented cartilage grafts in nasal dorsum management and do not wrap them into endogenous or exogenous sleeve material thus preventing the delay for vascularization of cartilage grafts, which is directly related to obtain durable results. By this way, durable results and smooth nasal dorsum can be maintained.

The Effect of Selenium on Ischemia-Reperfusion Injury: An Experimental Study on a Transverse Rectus Abdominis Musculocutaneous Flap Model.

BACKGROUND: The aim of this study is to investigate effects of selenium and enlighten the possible mechanism of action in a rat transverse musculocutaneous flap model following ischemia-reperfusion injury. MATERIALS AND METHODS: In this study, an experimental model, which mimicked free tissue transfer, was applied. Twenty-four male Wistar Albino rats were divided into a control group (N = 12), and a selenium treated group (N = 12). A superiorly based transverse rectus abdominis musculocutaneous (TRAM) flap was elevated and an ischemic insult for 4 hours was given. In selenium treated group (Group 2), sodium selenite (0.625 mg/kg) was injected intraperitoneally (i.p), 2 hours before the induction of ischemia. Six rats from each group were sacrificed at 24 hours after the operation and malonyldialdehyde (MDA), nitric oxide (NO), and glutathione (GSH) levels were measured biochemically, whereas the intensity of neutrophil infiltration was evaluated. For the rest of the rats in Group 2, sodium selenite was injected at the same dose everyday to the postoperative 10th day, in which the remaining 6 rats from each group were sacrificed. On postoperative 10th day, flap viability was assessed along with the evaluation of intensity of neovascularization. RESULTS: In Group 1, MDA levels were higher significantly (P < 0.05) when compared with Group 2. No statistical difference, however, was found for NO (P > 0.05), and GSH (P > 0.05) levels among Group 1 and 2. Neutrophil infiltration was more intense in Group 1, when compared with Group 2 whereas neovascularization was more abundant in samples of Group 2. Group 2 shows higher average flap surface areas when compared with Group 1 (P < 0.05). DISCUSSION: The results of this study demonstrated the preventive effect of selenium against ischemia-reperfusion injury by reducing tissue necrosis in muscle flaps possibly by decreasing MDA, increasing neovascularization, and decreasing neutrophil infiltration, thus suppressing inflammation.

Dorsal Intercostal Artery Perforator Propeller Flaps: A Reliable Option in Reconstruction of Large Meningomyelocele Defects.

Several options have been reported for the reconstruction of myelomeningocele defects. In this article, we present our experience on soft tissue reconstruction of myelomeningocele defects by using island propeller dorsal intercostal artery perforator (DIAP) flaps. Between January 2008 and February 2014, all newborns with large myelomeningocele defects (13 newborns) were reconstructed with island propeller DIAP flaps. All flaps survived completely. In 8 patients out of 13, venous insufficiency was observed which then resolved spontaneously. Flap donor sites were closed primarily. Myelomeningocele defects with a diameter larger than 5 cm require reconstruction with flaps. To mobilize a well-vascularized tissue over the defect without tension in which the suture lines will not overlap over the midline where the dura is repaired and over the meninges is one of the goals of reconstruction for such defects. Perforator propeller flaps enable us to reach those goals. Use of perforator flaps provides 2 important advantages, namely, more predictability and also more freedom in mobilizing flaps toward the defect. This study proves the reliability of DIAP propeller flaps in the reconstruction of myelomeningocele defects.

Giant Solitary Fibrous Tumor of Orbit.

Solitary fibrous tumors (SFTs) have been reported in various locations in the body. Solitary fibrous tumors are extremely rare tumors, especially when located in the orbit. Diagnosis of SFT cannot be made based on histopathology only because it exhibits a variable microscopic appearance, and necessitates immunohistochemistry to confirm the diagnosis. A 51-year-old man was admitted to our clinic for the evaluation of a mass bulging in his left eye. Clinical examination revealed a painless mass extruding out of the orbital cavity with dimensions of 8 × 7  cm. Exenteration of the left eye including the upper and lower eyelid and reconstruction of the orbital cavity using a temporoparietal fascia flap and a temporal muscle flap was performed. SFT of orbital region is known as a slow growing and painless tumor. Based on previous studies, increased mitotic rate of the tumor gives the impression that the tumor has a malignant nature. Until now a small number or orbital SFTs were reported and none of them presented with a giant mass protruding out of the orbital cavity. We present a unique case of orbital SFT filling the whole orbital cavity and protruding outward as a giant mass. This case has been reported to expand our knowledge in this debated entity.

Nasal tip contouring using lower lateral cartilages.

Nasal tip management is the most important and challenging part of rhinoplasty surgery. For nasal tip management, optimal nasal tip projection and rotation must be maintained. For this reason, several methods have been developed to obtain optimal results. In this article, we share with the rhinoplasty surgeons how we use cartilage grafts for nasal tip projection, nasal tip shaping, and maintaining natural and symmetric appearance and avoid "visible cartilage" problem by using a simple and easily applicable method. After performing standard open rhinoplasty techniques, we used the cephalic portion of the lower lateral cartilages to overgraft the already placed numerous layers of shield or onlay grafts. All the cartilage grafts are sutured in their place to prevent malpositions or undesired angularities. We operated on 1480 patients between September of 2002 and September of 2009 for rhinoplasty. Ages of the patients range from 18 to 58 years with nasal tip ptosis. We performed 1235 primary rhinoplasties and 245 secondary rhinoplasties. Of 365 patients, who were followed up regularly, 330 (approximately 90%) were operated on according to this technique and were included in the study. By using such an overgrafting technique for nasal tip, we obtained satisfactory results both by the patients and by the surgeons. Satisfactory results and being a facilitating method for shaping of nasal tip are the advantages of this technique.

The use of high-density porous polyethylene as a custom-made nasal spreader graft.

The concept and technique of using high-density porous polyethylene (HDPP), a nonresorbable synthetic material, for nasal spreader grafts, are presented. This material is thought to be particularly useful in revision (secondary or tertiary) rhinoplasty, in which internal valve collapse frequently is confronted and septal cartilage often is unavailable because it has been harvested for spreader or other grafts. Sold as a thin plain sheet (0.85 x 38 x 50 mm) that can be cut to an appropriate size for spreader grafts, HDPP is a ready-to-use material commercially available on the market. Because HDPP permits ingrowths of fibrous tissue inside and around, it is a nonabsorbable material that stabilizes the upper lateral cartilages in their new position and maintains the appropriate internal valve angle. The authors used this material for 15 patients undergoing secondary (n = 12) and tertiary (n = 3) rhinoplasty because of valvular collapse. During the mean follow-up period of 16 months (range, 8-30 months), neither complication nor recurrence of airway obstruction occurred.