Eight years of clinical experience with digit replantation: Demographic characteristics and outcomes.

BACKGROUND: Despite surgical and technical advances in microsurgery, it is still difficult to obtain satisfactory results after replantation of finger amputation. The aim of the present study was to discuss some of the many factors that can affect the success rate of replantation. METHODS: A retrospective analysis of 60 patients with 85 finger replantations was performed. Revascularizations and replantations proximal to the metacarpophalangeal joint were excluded. Demographic characteristics of the patients, place of injury, mechanism of injury, level of amputation, and success rate were examined. RESULTS: A total of 53 male and 7 female patients with mean age of 31 years were included in the study. Index finger (27%) was the most commonly replanted digit. Left side was the more affected, with 62%. Mechanism of injury was crush in 56%, guillotine in 23%, and avulsion in 21% of replanted digits. Success rate was 81%, 53%, and 36% in guillotine, crush, and avulsion injuries, respectively. CONCLUSION: In conclusion, the injury type and personal variables are very important in the rate of replantation success. Knowledge about the effects of different factors on the results of replantation surgery will provide guidance to hand surgeons in order to inform patients and their relatives properly.

Clinicopathological evaluation of Marjolin ulcers over two decades.

Malignant changes arising on the previously traumatized or chronically inflamed skin are defined as Marjolin ulcers. They can develop on many different lesions but frequently they are detected on burn scars. Histopathologically, Marjolin ulcers are mostly diagnosed as squamous cell carcinoma and they need special attention when especially located on the lower extremities. In this study, 63 patients treated for Marjolin ulcers between January 2000 and March 2015 were evaluated according to etiology, histological differentiation, primary tumor size, patient age and anatomical localization. Medical records of these patients were reviewed retrospectively. Mean age was 49.7 years. Average interval between the first injury and carcinoma development was 37.9 years. Most frequent etiologic factor was burn scars with 82.5%. Foot was the most frequently affected site with 28.6% and scalp was the second most frequent localization with 25.4%. Squamous cell carcinomas were detected in 88.9% of the patients and basal cell carcinomas were detected in 11.1% of the patients. For treatment, excision and grafting was performed for 48 patients (76.2%), excision and local flaps were used for 10 patients (15.9%) and excision and free flaps were used for five patients (7.9%). Regional lymph node dissection was performed for 12 patients (19%). Average follow up period was 46.5 months. Local recurrences were detected in nine patients (14.3%). In conclusion, Marjolin ulcers are aggressive tumors that require special care. In order to prevent life threatening sequelas of this entity, it is important to know basic aspects of clinical progress, prognostic factors and treatment modalities.

The Effect of Omeprazole Usage on the Viability of Random Pattern Skin Flaps in Rats.

BACKGROUND: Necrosis of random pattern flaps caused by inadequate blood flow, especially in the distal part of the flap is one of the biggest challenges in reconstructive surgery. Various agents have been used to prevent flap ischemia. In this study, we used omeprazole, which is a potent inhibitor of gastric acidity to increase flap viability. METHODS: In this study, 35 Wistar-Albino type rats which were divided into 5 equal groups were used. Random-pattern dorsal skin flaps were raised in all groups at seventh day of the study. Group 1 was accepted as control group, and the rats in this group was only given distilled water intraperitoneally for 14 days. Group 2 and group 3 received 10 and 40 mg/kg omeprazole daily for 14 days, respectively. Group 4 and group 5 were given distilled water for the first 7 days and then after the operations they received 10 and 40 mg/kg omeprazole daily for 7 days, respectively. Survival rates of the flaps were examined seventh day after elevation of the flaps by digital imaging and scintigraphy. After assessment of the amount of necrosis, number of vascular structures were counted histopathologically. RESULTS: Percentage of flap necrosis was found to be less in all omeprazole received groups. On digital imaging, percentages of flap necrosis in the study groups were statistically significantly lower than that of the control group (P < 0.001), but there was no significant difference between the study groups (P > 0.05).In the histopathologic specimens, it was detected that the mean number of vessels in proximal (a) and distal (c) portions of the flap in the study groups showed a significant increase when compared with the control group (P < 0.01 for groups 2, 4 and 5, and P < 0.05 for group 3). CONCLUSIONS: In conclusion, possible clinical usage of medications increasing gastrin during flap surgeries can be thought as a positive contributor. In this sense, this study showed that parenteral administration of omeprazole in skin flap surgery increases flap viability possibly by increasing gastrin levels.

Does crossover innervation really affect the clinical outcome? A comparison of outcome between unilateral and bilateral digital nerve repair.

Digital nerve injuries are the mostly detected nerve injury in the upper extremity. However, since the clinical phenomenon of crossover innervation at some degree from uninjured digital nerve to the injured side occurs after digital nerve injuries is sustained, one could argue that this concept might even result in the overestimation of the outcome of the digital nerve repair. With this knowledge in mind, this study aimed to present novel, pure, focused and valuable clinical data by comparing the outcomes of bilateral and unilateral digital nerve repair. A retrospective review of 28 fingers with unilateral or bilateral digital nerve repair using end-to-end technique in 19 patients within 2 years was performed. Weber's two-point discrimination, sharp/dull discrimination, warm/cold sensation and Visual Analog Scale scoring were measured at final 12-month follow ups in all patients. There was no significant difference in recovery of sensibility after unilateral and bilateral digital nerve repairs. Though there is crossover innervation microscopically, it is not important in the clinical evaluation period. According to clinical findings from this study, crossover innervations appear to be negligible in the estimation of outcomes of digital neurorrhaphy.

Analysis of Fractured Mandible Over Two Decades.

Mandible fractures have a special place within the injuries of the other bones of the maxillofacial system. In their management, cosmetic issues and functional aspects such as chewing, speaking, and swallowing become very important.In this study, a retrospective analysis of 419 mandible fractures in 283 patients was performed in relation to epidemiologic factors, treatment strategies, and complications. The average age was 32.14 years (4-69 years). The male/female ratio was 4/1. The most frequent etiologic factor was interpersonal violence (104 patients, 36.7%). The parasymphysis region was the mostly affected site (28.4%). A total of 157 patients (55.5%) were presented with single fracture and the rest with 2, 3, or 4 fracture lines on the mandible. The most common fracture combination was angulus-parasymphysis fracture combination (24.6%). Open reduction and fixation with mini plates and screws was the most preferred treatment strategy (48.2%). Transient short arch bars were not used intraoperatively for any of the patients. There was not any difference in terms of complications between the patients treated with plating systems and plating systems plus intermaxillary fixation.In conclusion, proper treatment of mandible fractures is critical. Except certain fracture types, the usage of intermaxillary fixation as an adjunct to fixation with plating systems is not necessary.

Four flap suspension technique for prevention of bottoming out after breast reduction.

PURPOSE: Bottoming-out deformity is accepted as the most important disadvantage of inferior pedicle breast reduction. For prevention of this deformity, different techniques are used in combination with inferior pedicle. In this study, we aimed to prevent bottoming-out deformity by producing an internal bra effect through combination of inferior pedicle technique with 2 superior and 2 inferior dermal flaps that were raised from each side of the pedicle. METHODS: Thirteen patients whose medical records became available during the follow-up period at Ankara Training and Research Hospital from January 2010 to January 2015 were included in this study. We retrospectively obtained patient medical records including demographic characteristics and clinical data. Superior dermal flaps were planned on both sides of the pedicle 2 cm inferior to the lower border of areola and inferior dermal flaps were planned 6 cm inferior to the superior dermal flaps. The superior and inferior dermal flaps were secured to the periosteum of the 2nd and 4th ribs respectively with permanent sutures. RESULTS: Preoperatively, the average distance between the inframammary fold and areola was 13.9 cm (range, 11-18 cm). The average amount of breast parenchymal resection was 745 g (range, 612-1,496 g). The average distance between the inframammary fold and the lower border of the areola was 7.9 cm (range, 7.5-9 cm) on the postoperative first-year measurements. CONCLUSION: In conclusion, according to our study, suspension technique to prevent bottoming-out deformity is associated with an easier technique without the need for alloplastic or allogenic materials. Since fixation is performed to the ribs instead of soft tissues like the pectoral fascia or muscle, we believe that this fixation is more long lasting and can be an effective alternative to other suspension techniques.

Alternative method for the reconstruction of meningomyelocele defects: V-Y rotation and advancement flap.

OBJECT: Skin grafts, skin flaps, fasciocutaneous flaps, muscle flaps, and musculocutaneous flaps have been used for closure of large meningomyelocele (MMC) defects that cannot be closed primarily. The V-Y rotation advancement flap technique has been used successfully for the reconstruction of defects in different areas of the body. In the present study, the authors report on their novel use of this technique in both a binary and a quadruple (butterfly) flap manner for closure of large MMC defects. They also present an algorithm that they developed for the evaluation of MMC defects. METHODS: Between January 2011 and November 2013, 17 patients (13 girls and 4 boys) with extremely large MMC defects that could not be repaired by direct primary closure underwent reconstruction of the defects with binary and quadruple V-Y rotation and advancement flaps. With the patient prone, the axillary apices, the most craniad point of the intergluteal sulcus, and the posterior axillary lines were marked, and a rectangular area on the back was designed. Edges of the rectangular area and the transverse and longitudinal diameters of the defect were measured and the presence of kyphosis was noted. These measurements and their proportions were used to develop an algorithm for patient assessment. While binary flaps were planned over the transverse diameter of the defects, quadruple flaps were planned over the bisectors of the defects, which were closed by elevating fasciocutaneous flaps. RESULTS: For patients whose defect diameter to back width ratio was between 0.30 and 0.50 and whose mean ratio of defect area to donor area was between 0.09 and 0.15, binary V-Y rotation and advancement flaps were used. When these values were in the range of 0.50-0.66 and 0.16-0.35, respectively, quadruple V-Y rotation and advancement flaps were preferred. The mean duration of postoperative follow-up was 10.4 months. With the exception of minor complications, such as partial necrosis of 0.5 × 0.5 cm in a quadruple flap, all the flaps healed uneventfully. CONCLUSIONS: With this study, closure of MMC defects with V-Y rotation and advancement flaps has been defined for the first time in the literature. The use of this technique with multiple flaps is an effective alternative to other flap options for the closure of large MMC defects. The algorithm developed in the course of this study should facilitate evaluation and reconstruction planning for patients with MMC defects.

Effect of topically applied sildenafil citrate on wound healing: experimental study.

Wound healing is a complex process that necessitates organization of different cell types and several signalling molecules. The aim of this study is to evaluate the effect of different concentrations of sildenafil citrate, which decreases cGMP degradation, on wound healing by secondary intention.This study was performed using 25 Sprague Dawley rats weighing 200-250 grams. 4 dorsal defects were created. Four different treatment modalities which were 1% and 5% sildenafil citrate gel prepared with carbopol, pure carbopol gel without any drug in it and 0,9% NaCl solution; were applied to each lesion of the same rat. Randomly selected five rats (25 rats in total) were sacrificed on 3rd, 5th, 7th, 10th, and 14th days; and the effect of each modality was evaluated by means of defect area measurement, histopathological examination and measurement of tissue hydroxyproline levels.Sildenafil citrate gel application decreased the defect areas in a dose independent manner starting from 3rd day and dose dependent manner after 7th day. By means of vascularization, sildenafil citrate increased vascularity starting from 3rd day. The strength of acute inflammation was superior in sildenafil groups starting from 5th day; and the amount and maturation of granulation in the wound bed, as well as the strength of chronic inflammation were superior in defects treated with sildenafil citrate as early as 7th day.

Comparison of autogenous cartilage, acellular dermis, and solvent-dehydrated pericardium for the prevention and correction of dorsal nasal irregularities: an experimental study.

BACKGROUND: Numerous materials have been used for the correction and prevention of dorsal nasal irregularities. Experimental and clinical studies have been useful but have provided insufficient results for several reasons, including the impossibility of obtaining pathologic specimens from aesthetic patients and imprecise experimental models. In this study, an experimental model for rhinoplasty is used for the comparative evaluation of solvent-dehydrated pericardium, acellular dermal matrix, and autogenous ear cartilage as onlay grafts for the prevention and correction of nasal dorsal irregularities. We used an experimental rabbit rhinoplasty model that has a human nose-like osteocartilaginous junction. Thus, our goal is to get a more realistic idea about the features of these three materials. METHODS: Thirty New Zealand rabbits weighing 2,100-2,550 g were used. The noses of the rabbits were evaluated with computerized tomographic measurements, "pinch" tests were performed for skin properties, and all were photographed before the surgical procedures. They were divided into three groups: Autogenous cartilage grafts were applied after the rhinoplasty operation in group 1, acellular dermal matrixes were used after the rhinoplasty in group 2, and pericardium allografts were used after the rhinoplasty in group 3. The rabbits were followed up for 4 months before they were evaluated by photography, computerized tomography, and "pinch" tests for the skin properties of the nose. Then they were killed for histopathologic evaluation. Adhesion and resorption rates of the onlay grafts were observed and subdermal thickness measurements were made to determine the fate of the grafts as well as their effects on the overlying skin. RESULTS: The major advantages of the allografts used in groups 2 and 3 are the ease of obtaining them without any donor site morbidity, shorter operative procedures, and lower distortion rates due to lack of cartilage memory. The results of this study conform to those of previous reports and demonstrate that the used allografts had no adverse effects such as ulceration or extrusion. The evaluation of the internal nasal valve angles before and after the surgical interventions showed that cartilage grafts created a spreader effect as expected, but acellular dermis and solvent-dehydrated pericardium did not. Despite a moderate graft reaction, pericardium or acellular dermis remained intact. None of the materials caused adhesion to the overlying skin. CONCLUSION: The results of this experimental study showed that acellular dermis (AlloDerm®) or solvent-dehydrated pericardium (Tutogen) may be used successfully as an "onlay" graft for dorsal nasal problems compared to autogenous cartilage, which is commonly used for this purpose. There has been more cartilage resorption than thought. This should be considered when overcorrection is performed. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Pulley reconstruction with different materials: experimental study.

The digital fibroosseous pulley system is essential for optimum function of the flexor tendons and the continuation of normal hand functions. Different materials have been used for pulley reconstruction in the literature but the ideal material is still controversial. In this study, after the excision of the A2 pulley, pulley reconstructions were performed by using acellular dermal matrix, solvent dehydrated bovine pericardium, fascia lata, and free tendon graft in the rabbit model. The animals were killed at the 8th and 12th weeks and subjected to biomechanical testing. Tendon excursion and work of flexion values were calculated for each digit of the rabbits. As a result, all the reconstructed pulleys were functioning well without a statistically significant difference between the experimental groups. Pulleys reconstructed with acellular dermal matrix and solvent-dehydrated bovine pericardium appear to have the potential to function as effective pulley substitutes.

Pinocchio nasal deformity secondary to lymphangioma circumscriptum.

Pinocchio or Cyrano nasal tip deformity is a rare situation that develops secondary to the soft tissue tumors underneath. In literature, there is only one case reported with Pinocchio nasal deformity secondary to cavernous lymphangioma. In this study, we present a Pinocchio or Cyrano nasal deformity with skin involvement secondary to lymphangioma circumscriptum.

Rhinoplasty model in rabbit.

BACKGROUND: Rhinoplasty has become one of the most frequently requested and performed surgical procedures for both functional and aesthetic purposes. As an attention-attracting prominence, even the slightest disfigurement of the nose causes serious disturbance to the patient before or after the operation. Functional problems also cause discomfort. For these reasons, postrhinoplasty complications are regarded as challenging problems for both for the patient and the surgeon. Some cases necessitate grafts for better aesthetic or functional outcome, but there is still controversy over the preference for autogenous or allogenous grafts, both for primary and secondary cases. Evaluation of autogenous and allogenous grafts implanted in the nose is quite challenging for several reasons, including the possibility of unpredictable complications leading to catastrophic disfigurements, the impossibility of obtaining pathologic specimens, and the need for a long follow-up period for stable results. An experimental model for rhinoplasty, fulfilling the need for precise evaluation, was planned and performed after anatomical observation of the noses of rabbits. METHODS: Fifteen adult New Zealand rabbits were used, five for the anatomical evaluation and 10 for the rhinoplasty model. Computed tomographic images and measurements were obtained before and after the surgical processes. RESULTS AND CONCLUSION: This experimental model for rhinoplasty has not been reported in any previous studies. This study demonstrates the surgical anatomy of the rabbit in detail and constitutes a guide for researchers as a convenient experimental model for rhinoplasty, with all stages similar to those performed on humans.

Multi-centric basal and squamous cell skin malignancies of the craniofacial region.

The etiology of skin malignancies is evaluated as multi-factorial. The human phenotype, syndromes, precursor lesions, and immunologic differences play as risk factors as well as environment. Twenty-seven patients with multi-centric skin malignancies investigated as if having predisposing syndromes. The etiological factors and the classification of skin malignancies are assessed. We last discussed about the management options. The mean age was 47 (9-91). Men to women ratio was 16:11. Four out of 27 patients having multi-centric skin malignancies were realized as syndromic. The localization of these tumors was entirely at the head and neck region. Ninety-eight areas were distinguished as having skin malignancies in 27 patients. Sixty-one incisional biopsies for type analysis and 37 excisional biopsies were handled. Of the 98 malignancies, 24 were squamous cell cancer, 67 were basal cell cancer, and seven were basosquamous cell cancer pathologically. Wound closures were carried out as primarily in 39 excisions; using skin grafts in 21 excisions, local flaps in 28 excisions, and distant flap procedures in 10 regions. The follow-up period was between six and 25 months. No complications or recurrences were seen. Eight patients applied with new lesions on new regions, six patients had excision, and two were treated with radiotherapy.

Examination of the skin perforators of the posterior tibial artery on the leg and the ankle region and their clinical use.

BACKGROUND: There are many treatment alternatives for reconstruction of leg and foot defects. One of these treatment alternatives includes local flaps. A detailed understanding of the blood flow of the leg region is essential for producing new alternatives for the reconstruction of defects of this region. METHODS: The leg and foot region blood flow was examined on 11 fresh cadavers, and perforators of this region were examined in three zones. Perforator numbers and their diameters were defined at this region. It was determined in cadaver studies that especially zones I and II were more suitable for the planned flaps based on perforators of the posterior tibial artery. In a clinical study that accompanies this anatomical study, eight patients underwent reconstruction by flaps based on the perforators of the posterior tibial artery. RESULTS: Patients were followed for 3 to 14 months. In three patients, venous drainage problems had developed, and in one of them, partial flap loss had developed. This partially necrosed region was left to heal by secondary intention. Venous drainage problems resolved in 5 to 7 days in the two remaining patients. No other complications were seen. CONCLUSION: Regarding the results of the clinical study, the authors observed that this flap can provide the desired soft-tissue support for defects that expose the bones, tendons, and neural and vascular bundles.