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.

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.

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.

In-vitro Comparison of Antimicrobial Efficacy of Various Wound Dressing Materials.

UNLABELLED: Many new antimicrobial dressings have been used for the treatment of or protection against wound infection since the early 1980s. There are many different wound dressings such as silver, povidone iodine, and chlorhexidine impregnated materials on the market today. Various manufacturers assert that their dressings are the most effective and therefore should be preferentially employed. However, it is difficult to find a study that clearly identifies the most effective antimicrobial wound dressing. METHODS: Eight different commercially available wound dressing materials were compared in terms of their antimicrobial effectiveness on 18 different microorganisms via disk diffusion test (Kirby-Bauer Method) on Mueller-Hinton (MH) agar. Among the 16 bacterial and 2 yeast species grown on MH agar plates, Contreet was the most effective antimicrobial dressing tested (P <0.001). RESULTS: A statistical difference was not found concerning efficacy against gram-positive and -negative bacteria among any of the materials except for Aquacel Ag and Inadine, the activity of which were found to be higher on gram-positive bacteria compared to gram-negative bacteria (P = 0.029, P = 0.030). In-vitro data suggest that Contreet is the most effective for topical treatment of contaminated wounds. CONCLUSION: Further methods of assessment, including the use of infected animal models and clinical studies, will be necessary to better understand the antimicrobial efficacy of these dressings .

Reconstruction of the oral commissure with the use of a new technique: the asterisk design.

Microstomia reconstruction due to the presence a blunted oral commissure is a challenging task because it requires the restoration of intricately balanced distinct layers of tissues: the oral mucosa, the orbicular muscle, the vermilion border, and the perioral skin. The reliability of commissural reconstruction depends on 2 factors: the first one is breaking the contraction vectors causing blunting of the commissure and the second one is restoring the integrity of the oral sphincter. We have used local skin, vermilion border-muscle, and mucosa flaps designed in an asterisk pattern to break the contraction vectors and have paid certain attention to the restoration of the sphincter function of the circular muscle fibers. Our results have shown that, with the use of our asterisk design, a new commissure aesthetically comparable to the natural one can be created with the reestablishment of reliable oral competence.

Surgical treatment of an exposed orbital implant with vascularized superficial temporal fascia flap.

Orbital implants are often used for the correction of volume deficit after enucleation or evisceration. An orbital implant enhances aesthetics and improves mobility of the subsequent prosthetic eye. With advancements in technology and techniques, implant-related complication rates have been decreased. However, implant exposition as one of the most common complications of socket surgery is still a problem for the oculoplastic surgeon. Many factors are thought to cause orbital implant exposure: Large implants, tension on the wound, and textured surface of the implant may cause a breakdown of the covering layers over the implant. Inadequate fibrovascular ingrowth into the porous implant is the most important factor. Various surgical methods have been described to cover the defect, most offering the use of various tissues as a graft, which are not always satisfactory. We describe a case with silicone implant exposition that was managed with a vascularized superficial temporal fascia flap. According to our knowledge, this is the first article reporting the usage of a vascular tissue in the management of an orbital implant exposure.

Intraarticular hyaluronic acid injection for the treatment of reducing and nonreducing disc displacement of the temporomandibular joint.

Temporomandibular dysfunction (TMD) has been established as a therapeutic challenge in the plastic and maxillofacial clinics. The current treatment recommendations for TMD include resting the jaw, soft diet, and pain medication with nonsteroidal analgesic agents. If conservative and noninvasive techniques do not work, more invasive techniques may be considered. The main goal of this study was to assess the safety and clinical utility of intraarticular injection of sodium hyaluronate for the treatment of symptoms associated with internal derangement of the temporomandibular joint (TMJ). In this prospective study, 40 TMJs of 33 patients who have TMD were treated with intraarticular sodium hyaluronate injections at weekly intervals for 3 weeks. Pre- and postinjection pain intensity, the presence of joint sounds, and interincisial distance were documented. The follow-up period was 12 months. There was a statistically significant reduction of pain intensity (P < 0.01) and joint sound (P < 0.05) in all patients. This study shows that intraarticular hyaluronic acid injection for the treatment of reducing and nonreducing disc displacement of TMJ is an effective and safe management.

Granulocyte-colony stimulating factor improves the survival of ischaemic skin flaps by the induction of angiogenesis.

In this study the effects of granulocyte-colony stimulating factor (G-CSF) on angiogenesis and the survival of ischaemic skin flaps are evaluated. Thirty adult Wistar rats were equally randomised into three groups. Caudal-based, ischaemic skin flaps of 10 x 3 cm were designed on the back and injected with saline in group 1 and with 100 microg/kg G-CSF in groups 2 and 3. The injections were performed just prior to flap elevation in groups 1 and 2 and 2 days earlier in group 3. Peripheral leukocyte counts, tissue myeloperoxidase enzyme assays, necrotic to total flap area ratio (NA/TA) calculations, flap tissue inflammation gradings, immunohistochemical vessel counts, and electron microscopic evaluation of endothelial cells were performed on the 8th day. No significant difference was encountered between the groups in terms of the leukocyte counts, myeloperoxidase enzyme assays and inflammation gradings (P > 0.05), demonstrating the absence of an increased inflammatory response within the flap tissue. The surviving flap portions were observed to be increased with the application of G-CSF. The mean NA/TA results (when measured in situ) were 0.44+/-0.13 for group 1, 0.30+/-0.17 for group 2, and 0.22+/-0.16 for group 3. The difference between groups 1 and 3 was statistically significant (P = 0.009). The mean vessel count was 3.53+/-1.20 in group 1, 7.36+/-1.41 in group 2 and 7.43+/-0.92 in group 3. The differences between groups 1 and 2 and groups 1 and 3 were statistically significant (P < or = 0.001). Early apoptotic changes were encountered in the endothelial cells of group 1, while activated and proliferating endothelial cells were seen in groups 2 and 3 with electron microscopy. G-CSF promotes angiogenesis by increasing the number of activated and proliferating endothelial cells within the ischaemic flaps by the resettlement of G-CSF-stimulated endothelial progenitor cells into the ischaemic tissue. The overall result is an improved survival of ischaemic skin flaps. These effects are more pronounced when G-CSF is introduced 2 days prior to flap elevation.

The Efficacy of Topical Negative Pressure in the Management of Infected and Non-infected Wounds .

UNLABELLED:  This study evaluates the efficacy of a vacuum-assisted closure (V.A.C.® Therapy, KCI, San Antonio, Tex) device in the comparative management of clean and infected wounds. Vacuum-assisted closure was applied to 57 wounds of 51 patients. METHODS: Our protocol consisted of debridement of all necrotic tissue followed by vacuum-assisted closure therapy along with appropriate antibiotic administration. In 5 cases with peripheral circulation impairment, vacuum-assisted closure therapy was terminated due to a poor tissue response. In the remaining 52 wounds, healthy granulation tissue generation was observed. Wound cultures obtained from these patients prior to the start of vacuum-assisted closure proved the presence of infection in 31 wounds, while the other 21 wounds were free of infection. RESULTS: The average sizes of the infected and non-infected wounds were 55.77 cm2 and 57.94 cm2 prior to the start of vacuum-assisted closure, respectively, while they were reduced to 48.28 cm2 and 45.70 cm2 after the last session. At the conclusion of vacuum-assisted closure therapy, 42 wounds were skin grafted and 10 wounds were covered with skin/muscle flaps. CONCLUSION: Vacuum-assisted closure therapy is a reliable tool in the management of almost any type of wound, whether infected or not infected, unless major circulatory impairment interferes and acted as a contributory factor in wound formation. .

Reconstruction of extensive pilonidal sinus defects with the use of S-GAP flaps.

Pilonidal sinus is a chronic intermittent inflammatory condition that is predominantly located in the sacrococcygeal region. For the closure of uncomplicated small pilonidal sinuses, conventional therapeutic techniques including total excision of the sinus and leaving the defect open for secondary healing have been reported with varying success rates. However, the treatment of recurrent and extensive disease remains as a difficult condition. The ideal treatment should be associated with short hospital stay, minimal complication rates, and no disease recurrence. Secondary wound healing after large excision results in a chronic wound that requires cleansing and dressing changes for a long time. The condition also negatively affects the patient's social life. With the progression of reconstructive techniques, the lowest recurrence rates for the treatment of extensive disease have been reported after local flap usage. The purpose of the current article is to report the efficacy of superior gluteal artery perforator flap in the reconstruction of extensive sacrococcygeal pilonidal sinus defects. This perforator flap is a refinement of the classic gluteal musculocutaneous flaps, which have been popularly used for the closure of sacral pressure sores over many years.

Versatility of frontal island flaps in the reconstruction of periorbital soft tissue defects.

The reconstruction of large soft tissue defects in the orbital and maxillomalar region is a challenging task that necessitates the consideration of both functional and aesthetic outcomes. We used the frontal island skin flap in patients with full-thickness soft tissue defects of the periorbital and malar region. In the reconstruction of full-thickness defects of this particular region, the alternatives to this flap are other regional flaps or distant free flaps. Not every pedicled regional flap can be transferred to every defect and most of the time the application of distant free flaps increases the morbidity of the procedure. The surgeon must be capable of being able to select the most useful and comprehensive flap within a range of many alternatives. We present our experience in 10 patients with complex soft tissue defects in the maxillomalar and periorbital regions whose defects were reconstructed with frontal artery island skin flaps.

Effect of fresh and stored botulinum toxin a on muscle and nerve ultrastructure: an electron microscopic study.

The aim of this study was to compare the ultrastructural alterations of the muscle and nerve that appear following injection of freshly reconstituted and stored botulinum toxin A. Fifteen New Zealand white rabbits were assigned to 6 groups, and anterior auricular muscle was used for injections. Group 1 did not receive any injection and group 2 received saline injection. Groups 3 and 5 received fresh botulinum; muscles and motor nerves were harvested at 5 days and 12 weeks, respectively. Groups 4 and 6 received stored botulinum; muscles and motor nerves were harvested at 5 days and 12 weeks, respectively. Alterations in muscle and nerve ultrastructure were evaluated with electron microscopy. Degeneration findings in muscle after botulinum toxin injection revealed no significant difference between freshly reconstituted and stored toxin in the early period. When stored toxin was used, atrophic changes in the muscle were less severe than the fresh toxin at 3 months. On nerve evaluation, fresh toxin displays significant acute changes on nerve ultrastructure; however, fresh and stored toxin shows similar degeneration at 12 weeks.

Aplasia cutis congenita of the scalp and calvarium: conservative wound management with novel wound dressing materials.

Aplasia cutis congenita is a rare congenital disorder of skin and most commonly involves the scalp. The skull and dura underlying the defective skin may also be affected, relative to severity of the disease. The typical lesion is present at birth and ranges in size from 0.5-3 cm. The main complications of larger defects include infection, bleeding and trombosis that may be deadly. Therefore, prompt diagnosis and appropriate treatment are critical for avoiding the adverse outcomes. Controversy exists in the literature regarding the treatment of aplasia cutis congenita; both surgical and conservative treatment modalities have their proponents and opponents. We present a case of full thickness aplasia cutis congenital lesion bigger than 3 cm in diameter that healed with the application of novel wound dressing materials without any complications. The physiopathology, classification and treatment options of the disease are discussed.

The potential of microscopic sterile sponge particles to induce foreign body reaction.

The sterile sponges may lose a significant amount of lint during their routine use in surgery, which is usually neglected. We designed an experimental model to evaluate the potential of sterile sponges to lose lint and to induce foreign body reaction in surgically created wounds. In 15 Wistar rats, separate subcutaneous pockets were created. Left-sided pockets were temporarily packed with sterile sponges, while the right-sided pockets remained empty. All the pockets were then irrigated with sterile saline. The presence of microscopic sponge particles was evaluated in the irrigation materials. After 4 weeks, the presence of inflammation and foreign body reaction were evaluated histologically. Microscopic sponge remnants were present in 14 of 15 samples collected from the left sides. The presence of foreign body giant cells with ingested sponge particles and formation of well-defined foreign body granulomas were observed only in samples collected from the left sides. A statistically significant difference was observed between the two sides when the intensity of inflammation was graded (P= 0.012). Cotton sponges used in surgery are shown to have a potential of losing invisible microscopic particles that have a potential to induce foreign body reaction.

The additive effects of carnitine and ascorbic acid on distally burned dorsal skin flap in rats.

BACKGROUND: The purpose of this study was to determine the effects of combined use of L-carnitine and vitamin C on partially burned skin flap in an experimental rat model. MATERIAL/METHODS: In the rat dorsal skin, a 10 x 3 cm flap was marked. The most distal 3 x 3 cm part was burned to full thickness. Twenty-four rats were randomized into four groups with 6 animals in each. Group 1 was simply followed up. Group 2 was given 0.5 mg/kg vitamin C per day for 7 days, group 3 100 mg/kg carnitine per day for 7 days, and group 4 both carnitine and vitamin C. On the eighth postoperative day, the animals were sacrificed and examined. The surviving and necrotic areas were determined by macroscopic examination and measured with a planimeter. RESULTS: The areas of flap necrosis were measured. The median surviving areas and areas of flap necrosis, respectively, of the groups were: group 1, 16.0 cm(2) and 14.0 cm(2); group 2, 18.25 cm(2) and 11.75 cm(2); group 3, 20.0 cm(2) and 10 cm(2) ; and group 4, 23.75 cm(2) and 6.25 cm(2). The surviving areas of the groups were found to be significantly different (p=0.000). CONCLUSIONS: The risk of ischemia-induced necrosis in flap attempts made in damaged tissues may be reduced by the combination of two promising agents, L-carnitine and vitamin C. L-carnitine appears to be the major contributing factor that reduces necrosis, and vitamin C an additive agent.

Resorbable plate-screw systems: clinical applications.

OBJECTIVE: To evaluate the results we obtained from 37 patients referred to our clinics with resorbable plate-screw systems which have been claimed as biodegradable fixation materials and used in craniofacial, maxillofacial and orthopedic reconstructive procedures owing to their advantages such as biocompatibility, adequate biomechanical resistance, longer dwelling time, elimination through physiological routes without causing any foreign body reaction and/or significant sequaleae. METHODS: Resorbable plate-screw systems used in 37 patients between 2000-2003 for various craniofacial reconstructive procedures were evaluated as for their efficacy, and biocompatibility. RESULTS: Adequate fixation was obtained in all patients, excluding one case operated for mandibula fracture whose reconstruction was completed with titanium plate-screw system. No serious complication was seen except a granuloma and sinus formation on subciliary incision in one patient. CONCLUSION: Owing to their improved polylactic acid/polyglycolic acid ratio resorbable plate-screw systems which contain varying compositions of polylactic acid and polyglycolic acid copolymers are ideal fixation materials used favourably in maxillofacial, craniofacial and orthopedic reconstructive surgery in that they make effective fixation and have further advantages such as biocompatibility, adequate biomechanical resistance against distraction and compression forces in the early postoperative period, longer dwelling time and elimination from the body through physiological routes without causing any foreign body reaction or significant sequaleae.