The Surgical Strategy for the Intraorbital Foreign Bodies.

PURPOSE: Four patients with intraorbital foreign bodies admitting to our clinic between 2001 and 2011 are presented. Their clinical and radiologic findings and surgical strategies are discussed. OBJECTIVE: The success of surgery for the intraorbital foreign bodies largely depends on the determination of the exact localization of them. Radiologic examination should follow clinical diagnosis. Computed tomographic views are especially required to demonstrate the foreign body. MATERIALS AND METHODS: Four patients with different etiologies of trauma are presented. Each had computed tomography views for foreign body localization. All but 1 had surgery for removal of the object under general anesthesia. RESULTS: No complications were observed postoperatively. Only 1 patient is followed up without an operation due to the risk of damaging delicate structures that the foreign body is close to. He has no loss of function. CONCLUSION: Early removal of foreign bodies in orbital region is usually preferred due to the risk of neurologic damage and other complications. Surgical removal is quite challenging for foreign bodies like wood. Magnets can be used for metallic bodies.

Dilemma in pediatric mandible fractures: resorbable or metallic plates?

BACKGROUND: The aim of this study was to compare the efficiency of resorbable and metallic plates in open reduction and internal fixation of mandible fractures in children. METHODS: Thirty-one patients (mean age, 8.05 years; range 20 months-14 years) were operated on various fractures of the mandible (26 [60.4%] symphysis- parasymphysis, 12 [27.9%] condylar-subcondylar fractures, 5 [11.6%] angulus and ramus fractures). Twelve patients were treated with resorbable plates and 19 patients with metallic plates. Mean follow-up time was 41 months (11-74 months) in the metallic hardware group and was 22 months (8-35 months) in the resorbable plate group. Both groups were investigated for primary bone healing, complications, number of operations, and mandibular growth. The results were discussed below. RESULTS: Both groups demonstrated primary bone healing. Minor complications were similar in both groups. The metallic group involved secondary operations for plate removal. Mandibular growth was satisfactory in both groups. CONCLUSION: Resorbable plates cost more than the metallic ones; however, when the secondary operations are included in the total cost, resorbable plates were favourable. As mandibular growth and complication parameters are similar in both groups, resorbable plates are favored due to avoidance of potential odontogenic injury, elimination of long-term foreign body retention and provision of adequate stability for rapid bone healing. However, learning curve and concerns for decreased stability against heavy forces of mastication accompanied with the resorbable plates when compared to the metallic ones should be kept in mind.

Camouflage therapy in aesthetic surgery.

The use of makeup has been traced back to antiquity. Today, there are multiple reasons that makeup constitutes an important part of, and is a driving force in, almost every woman's life. The idea of using cosmetics for camouflage therapy, especially in the postoperative period, originates from the illusionary effect, which is thought to diminish the post-traumatic stress frequently seen after facial operations. The patients will feel better following cosmetic application, as they will see themselves better.

Benefits of conservative "wait and see" approach for recurrent plantar keloid.

Keloid formation of the plantar region is rare and a unique challenge to surgeons. We used a conservative "wait and see" approach for recurrent keloid in the plantar region in two patients and recommended that the patients used custom-made shoes. Both patients were pleased with the result. The keloids regressed and flattened. During our minimum of five years follow-up the patients had no pain, tenderness, paraesthesiae, or problems with walking. We found no complications. Keloids should not be treated aggressively, and in plantar keloids the conservative "wait and see" approach may provide successful results without any complication.

Necrotizing fasciitis of the perineum.

BACKGROUND: Necrotizing fasciitis is a severe soft tissue infection characterized by rapidly progressing necrosis, involving subcutaneous tissues. This rare condition carries a high mortality rate and requires prompt diagnosis and urgent treatment with radical debridement and antibiotics; but early diagnosis, which is essential to successful treatment, remains a challenge. METHODS: Physical examination findings, preoperative and operative findings, histopathological results of the structure, and follow-up results of the patient are discussed with related reports. RESULTS: A 15-month old girl had a history of trivial perineal dermatitis after treatment of anemia and pneumonia. Perineal dermatitis progressed fastly as necrotizing fasciitis which was successfully managed with intensive medical treatment, surgical debridement and reconstructive surgery. CONCLUSIONS: Lack of cutaneous findings early in the disease makes the diagnosis challenging, so a high suspicion is essential. Recovery of the patient from this life-threatening condition needs a multi-disciplinary approach involving pediatrics, pediatric surgery, and plastic and reconstructive surgery.

The surgical treatment of plagiocephaly.

AIM: Anterior plagiocephaly usually occurs with premature synostosis of the ipsilateral half of the coronal suture. The forehead is flattened on the affected side, with a backward and upward displacement of the affected orbit. The bulging of the calvaria may occur in the contralateral parietal area. MATERIAL AND METHODS: This article presents the surgical techniques used over 7 years to treat plagiocephalic children. Eleven patients with unilateral coronal synostosis treated during 2003-2010 were analyzed retrospectively. The study included reviews of pre and postoperative computed tomography scans, operative techniques, clinical outcomes and complications. Unilateral orbital advancement with "tongue in groove" was performed in 5, and bilateral orbital advancement in 6 cases. Pre and postoperative anthropometric measurements were used to document the amount of advancement of the elevated and recessed orbita, and the amount of withdrawal of the contralateral side. RESULTS: The mean age of the patients at time of surgery was 11 months. The preoperative values of the orbital height and retrusion were 0.68 cm and 1.87 cm, respectively. They were recorded as -0.1cm and 0,63 cm, postoperatively. Mean follow-up was 36 months, neither neurological sequelae nor other significant complications were encountered. CONCLUSION: The surgical corrections have resulted in significant improvements in skull shape and high patient/parent satisfaction.

Is polymethylmethacrylate reliable and practical in full-thickness cranial defect reconstructions?

OBJECTIVE: The study aimed to evaluate the success of polymethylmethacrylate cranioplasty combined with various soft tissue coverage techniques in repairing full-thickness cranial defects, to compare our results with similar studies published before, and to describe a simple method of implant premolding. METHODS: A total of 17 patients who had cranial defects due to various etiologies underwent polymethylmethacrylate cranioplasty. In 10 patients, the implant premolding method was applied. The soft tissue coverage was obtained by primary closure, local flaps, or free flaps. RESULTS: The follow-up period ranged from 36 hours to 5 years. Only 1 implant became exposed among the 17 patients. One patient died 36 hours after the surgery because of myocardial infarction. The remaining 15 patients had no early or late postoperative complications. Good contour restoration and stable reconstruction of the calvarial defects were realized, and a successful combination of various soft tissue coverage techniques was achieved. CONCLUSIONS: We concluded that polymethylmethacrylate was a cheap and durable material, useful in full-thickness calvarial defect reconstructions. It can be combined with any soft tissue coverage techniques except skin grafting. In most cases, the simple premolding methods are useful for both defect matching and preventing tissue damage due to exothermic reaction of the material.

A method for flap monitoring based on bioelectrical-resistance analysis.

Axial pattern flaps are characterized by a single vascular pedicle that supplies the whole flap and carry the danger of flap loss. For this reason, monitoring and early identification of vascular perfusion is important for flap prognosis. The most commonly used method for flap monitoring is clinical assessment, but it has certain limitations. The bioelectrical properties of tissues can be affected by ischemic conditions, and a preliminary study showed that the bioelectrical resistance of blood was decreased under thrombotic conditions. In this controlled study, the resistance values of the axial flaps were calculated during thrombosis. A total of 28 rats were randomly divided into a control group (n = 14) and an experimental group (n = 14). Axial flaps were elevated based on the inferior epigastric pedicle. For the ischemic group, microvascular clamps were placed in the ischemic group to produce artificial thrombosis from day 1 of the experiment. Bioelectrical resistance was measured every 30 minutes for the first 6 hours and then daily after that. The resistance values from the ischemic group decreased progressively, and 150 minutes after the clamping, the difference became statistically significant (P < 0.05). The results showed that the assessment of flap resistance is a valuable tool and may allow early recognition of a compromise in the vascular system before clinical signs become obvious.

Chondrogenic effect of the perichondrium graft on the internal derangement and osteoarthritis of the temporomandibular joint of the rabbit.

Internal derangement of the temporomandibular joint is usually defined as the disruption of the condyle and disc relationship. In addition to this description the other elements of the joint including the cartilage surface, synovial fluid, the ligaments and the bony surface itself demonstrate varying degrees of pathology in concordance with the stage of the internal derangement, as well. This study is designed to create an osteoarthritic model in the rabbit temporomandibular joint. A 2×2mm defect was performed on the cartilage surface of the both condyles of each animal (n=30). The osteoarthritic changes were demonstrated by computerised tomography sections. The right joints of the animals constituted the control group and the left, the study group. At the time of the defect generation, a perichondrium graft from the animal's ear was implanted onto the defect in the study group. The control group was left to heal secondarily. The joints of three randomized groups of 10 animals for each were inspected at the 4th, 6th, and 8th weeks. Cartilage regeneration and regression of the osteoarthritic changes were demonstrated in the study group both in the 6th and 8th week groups. However, the control group showed less cartilage regeneration and progression of the osteoarthritic changes in all weeks, with progression with time. The perichondrium graft has demonstrated chondrogenic effect on the condyle and this in turn changed the progression to internal derangement.

Giant craniofacial immature teratoma with primary intracranial lesions.

Teratomas can occur in almost any region of the body and are the most common extragonadal germ cell childhood tumors. Immature teratomas in the head and neck region cause severe deformity and threat life because of several reasons. Imaging investigation (ultrasonography, computed tomography, magnetic resonance imaging) is of outmost importance for the diagnosis and preoperative planning, considering that the total surgical resection of the teratoma constitutes the treatment of choice. Untreated teratomas have mortality rates of 80% to 100%. In this study, a giant craniofacial immature teratoma having both intracranial and extracranial primary lesions is reported. As a conclusion, intracranial primary lesions should be kept in mind in extracranial head and neck immature teratoma cases.

Lower lip reconstruction with neck flaps as a salvage procedure.

There are many surgical reconstructive techniques after lower lip ablation. As the lower lip defect gets larger, the required reconstructive techniques become more complex. Despite the indication of free flaps, some situations require local flaps for reconstruction. These situations may be donor and/or recipient vessel problems or systemic disorders of the patient. In this article, a total lower lip reconstruction technique using the neck skin was described. The technique was applied successfully in 2 cases. An acceptable cosmetic result was obtained, and there were no early or late surgical complications in 2 years' follow-up. The patients were satisfied with the results. Lower lip reconstruction with the neck flaps must be kept in mind as a quicker alternative and a salvage method when the free flaps cannot be applied.

Salvage of suboptimal results in a reconstructed ear: nonsurgical reshaping with triamcinolone.

BACKGROUND: Ear reconstruction with autologous tissues and creating a natural-appearing ear is a difficult, multistage surgical procedure. Problems, such as a thick skin or an inadequate cartilage-flap relationship, may cause obliteration of the framework details. A nonsurgical technique to improve auricular definition is described. MATERIALS AND METHODS: Twenty-six patients with reconstructed ears due to inadequate auricular definition were enrolled in the study. To achieve a better auricular shape, triamcinolone acetonide injections up to 4 sessions were applied. Results of injections were evaluated by improvement of ear contours, quality of detail, frequency of injections, and complications. In addition, histopathologic studies were carried out in 8 patients. RESULTS: The results were satisfactory. Significant recovery was observed in auricular definition in all patients. There were no major complications observed as a result of the use of steroids during the long follow-up period, suggesting that our technique was safe. CONCLUSIONS: The solution to unfavorable results of a primary auricular reconstruction generally requires extremely difficult and challenging procedures. In selected patients, triamcinolone injections may be a remedy and may be helpful in avoiding complex surgical procedures.

Neural fibrolipoma of a digital nerve of the index finger without macrodactyly.

We present a case of neural fibrolipoma arising from the digital nerve in the index finger of the right hand. A 31-year-old man was referred with a soft tissue mass in the ulnar aspect of the index finger of his right hand, which had gradually enlarged during the past seven years. Histological examination of an excisional biopsy specimen identified a neural fibrolipoma, which is a differential diagnosis of a lipomatous lesion of the digits.

Functional reconstruction in large and complex soft tissue defects of forearm and hand with multifunctional anterolateral thigh flap.

OBJECTIVES: The aim of this study was to evaluate the results of free anterolateral thigh (ALT) flap reconstruction for large and complex soft tissue defects of forearm and hand. PATIENTS AND METHODS: Thirteen patients (11 males, 2 females; mean age 32.5 years; range 18 to 55 years) underwent free ALT flap reconstruction for forearm and hand defects. The etiology of defects was crush injury in nine patients, tumor excision in two patients, electric burn in one patient, and unstable scar excision in one patient. In five patients a flow through ALT flap was used to reconstruct vascular defects. In tree patients a vascularised fascial ALT flap was used to reconstruct the tendon defects and in five patients neurosensory ALT flap was used. Patients were followed for 44+/-14.6 months. Chen classification was used to evaluate functional outcomes at the end of the postoperative first year. RESULTS: All flaps survived completely in 11 patients. In the other two patients marginal necrosis was observed. These areas with necrosis healed after debridement and daily dressings. The functional results were satisfactory in 11 patients according to Chen classification (6 patients Chen I and 5 patients Chen II) and poor in two patients (Chen III). CONCLUSION: The anterolateral thigh flap represents an excellent option for covering various complex defects in the forearm and hand. The flap provides a thin, pliable, vascularized tissue for covering the exposed tendons, nerves, bones, and reconstruct deficiencies.

End-to-side anastomosis with "open-Y" technique on small vessels to increase patency and facilitate anastomosis.

We report a different type of microvascular end-to-side anastomosis using "open-Y" technique to increase small recipient vessel size and provide eversion of the vessel ends in end-to-side anastomosis. The purpose of this study was to compare the effectiveness of this technique with conventional end-to-side vessel anastomosis. Twenty rats were used to assess the open-Y technique in end-to-side anastomosis between carotid arteries and external jugular veins and another 20 rats constituted the control group in which conventional end-to-end anastomoses were performed. Statistically, the results at 1 hour and 2 weeks after the procedures favored the open-Y technique. When used in end-to-side anastomosis, the open-Y technique both provides eversion and increases the diameter of the vessel, which in turn ease the procedure and provide a higher rate of patency especially in vessels with a diameter of 0.5 mm.

In-vitro comparison of the lengthening and biomechanical properties of three tendon lengthening techniques.

OBJECTIVES: Clinically, the Z-plasty lengthening is the only method used in the upper extremity, whereas several different techniques such as the Vulpius and Baker are used in the lower extremity. In this study, the usage of the modified Vulpius and Baker tendon lengthening techniques in the upper extremity was investigated. MATERIALS AND METHODS: Vulpius and Baker techniques are modified by changing their application site in 90 sheep fore-limb deep flexor tendons using three randomly divided groups. Z-plasty, V-Y-plasty (Modified Vulpius) and U-T-plasty (Modified Baker) techniques were used in groups I to III, respectively. Their elongation and biomechanical properties were compared. RESULTS: The Z-plasty technique provided significantly greater lengthening than the other two techniques, followed by the U-T-plasty technique. Failure load of the U-T-plasty technique was 60.7% higher than the Z-plasty technique and 45.4% higher than the V-Y-plasty technique. Repairs with the U-T-plasty and V-Y-plasty techniques were significantly stiffer than the repairs with the Z-plasty technique. CONCLUSION: The U-T-plasty technique may be a good alternative to the Z-plasty technique because of its easy application and better biomechanical properties, especially in cases that need moderate-sized elongation and early mobilization. But the restorative properties of this technique need to be observed on an in-vivo model.

A pedicled muscle flap based solely on a neural pedicle.

We tested the hypothesis that the intrinsic vascular plexus of the motor nerve could support viability in a rat hindlimb muscle flap. In a preliminary study, we examined the course and vascularity of the sciatic nerve, the peroneal nerve, and the peroneous longus muscle in the rat hindlimb via anatomic dissection, microangiography, and histologic study (n = 10 animals). On the basis of this examination, the peroneous longus muscle was chosen as our experimental model in this study. In 12 animals, the peroneus longus was acutely elevated, which severed all tendinous and vascular structures, this left the muscle pedicled on the motor nerve only (Group I). Animals in Group II underwent a staged elevation of the flap with division of the vascular pedicle, the tendon of insertion, and the tendon of origin during separate procedures that were 5 days apart (n = 12). Muscle viability was evaluated by gross inspection, measurement of muscle weight and length, nitroblue tetrazlium (NBT) staining, microangiography, and histology. NBT staining demonstrated that immediate elevation of the peroneus longus muscle flaps led to an average necrotic area of 80.6% +/- 9.8% (Group I). A significant improvement in viability was observed for muscle flaps of animals in Group II, with peroneus longus muscle necrosis averaging 25.6% +/- 9.3%. Microangiography demonstrated that the intrinsic vascularity of nerve was increased dramatically in Group II. These data support the hypothesis that the intrinsic vascular plexus of the motor nerve of a skeletal muscle can support at least partial viability of a muscle flap. However, this vascular axis is inadequate to support complete viability of a muscle flap if the flap is elevated immediately. If a staged elevation affects a surgical delay, the viability of a muscle flap elevated on a neural pedicle can be increased significantly. With adjustments in the delay procedure, this strategy may allow transfer of muscle flaps when maintenance or reconstitution of the primary vascular axis is not possible.

In vivo comparison of biomechanical, histological, and radiological properties of three techniques for tendon lengthening: an experimental study in rabbits.

Biomechanical, histological, and radiological properties of three different techniques of tendon lengthening - Z-plasty, modified Vulpius, and modified Baker - were investigated and compared. Sixty white female Angora rabbits (mean weight 4.1 kg, range 3.9 kg- 4.2 kg) were randomly divided into three groups: Z-plasty, V-Y plasty (modified Vulpius technique), and U-T plasty (modified Baker technique). Histopathological, radiological, and biomechanical properties were evaluated at the third and sixth postoperative week. Qualitative analysis of ultrasound examination showed that Z-plasty had the most irregular echo pattern at the third postoperative week, and had less echogenic areas at the sixth postoperative week. Histological evaluation showed that Z-plasty had significantly more formation of fibrosis and adhesion and less parallel homogeneous collagen fibres at the sixth postoperative week (p<0.05). U-T plasty had a significantly higher mean (SD) failure load (15.35 (1.89) N) than the other two methods during the third postoperative week (p<0.05). There was no significant difference in failure load between the groups at the sixth postoperative week. U-T plasty is a good alternative to Z-plasty technique for lengthening tendons, and it may be the first choice in those who need moderate lengthening of tendons and early rehabilitation because it is easy to do, heals better, and has good biomechanical properties.

Jack-like eversion by splitting the orbicularis oris muscle for reconstruction of the philtral column in secondary cleft lip.

The philtrum is an important aesthetic unit that contributes hugely to the characteristics of the human face. From March 2002 to May 2006 inclusive, a total of 16 patients with unilateral cleft lip nose were operated on to form a philtral column and obtain muscular continuity. Six of the patients were female and 12 were male, age range 5 to 30 years old. We used Millard's method, so rotation and advancement flaps were planned. A full thickness incision was made down to the orbicularis oris muscle and mucosa after the scar on the philtral column had been excised. The medial and lateral muscle flaps were exposed and split into two leaves at the coronal plane. The deepest part of the muscle flaps were sutured together to create a jack-like eversion. Skin and mucosa were then closed. The follow-up period ranged from 8 to 18 months (mean 11 months). Two visual analogue scales were used to assess the outcomes. Thirteen of 16 patients were satisfied with their good result. Three had moderate results. The advantages of the technique are: ease of use; the creation of an anatomically-natural philtrum while preserving the continuity and function of the muscle; sufficient augmentation of the philtral column by the jack-like eversion; and no donor-site morbidity.