The effect of external beam irradiation timing on skin graft survival.

BACKGROUND: The purpose of this study was to evaluate skin graft integrity after external beam irradiation in a rat model. METHODS: Forty-eight male Wistar rats were randomly assigned to 8 groups (A, B, C, D, A(c), B(c), C(c) and D(c)). A rectangular full-thickness skin graft was raised and reapplied to its original bed on the dorsum of each rat. Groups A(c), B(c), C(c) and D(c) were the control groups and were not given postoperative irradiation. After grafting, 25 Gy unfractioned cobalt(60) irradiation was administered to groups A, B, C and D on postoperative days 10, 20, 30 and 40, respectively. Histological samples were obtained 8 weeks after grafting. Dermal and epidermal thickness were measured by the KS-400 image analysis program. RESULTS: The difference in the epidermal and/or dermal thickness between the irradiated groups was not found to be significant. Furthermore, when histological features and the image analysis of the irradiated groups were compared with each other, there were no significant differences between the groups. CONCLUSIONS: Although we are aware that experimental results may not directly translate to the clinical setting, the present study indicates that external radiotherapy can be performed to skin-grafted areas as early as 10 days postoperatively.

Fasciotomy in crush injury resulting from prolonged pressure in an earthquake in Turkey.

OBJECTIVES: The authors report on the patients treated in a clinic who were injured in the earthquake that took place in north western part of Turkey in 1999 and was reported to be measured at 7.4 on the Richter scale. This catastrophe killed over 16 000 people while injuring more than 23 000 people. The type of housing was varied and entrapment occurred in single, two or more storey buildings. METHODS: 35 patients were admitted to the plastic surgery department after the earthquake. The hospital is about 400 km from the disaster site. Although all the transported victims had intravenous lines, few had adequate volume replacement. Sixteen had an urgent fasciotomy at the time of admission. The procedures were performed between 8 and 21 hours after extrication. After fasciotomy, all non-viable muscle content was removed but an attempt was made to retain as much viable muscle as possible. RESULTS: Amputation was required on four patients (25%). Fasciotomy incisions were closed with skin grafting in eight cases, and with primary closure in four cases. CONCLUSION: Prompt fasciotomy in earthquake victims will be both life saving and can prevent some of the severe and dangerous complications after crush syndrome.

Two in one: patient-controlled epidural analgesia (PCEA) to prevent erection and control pain in adult hypospadias-surgery patients.

Following penile surgery, erections are painful and may prejudice the result, because the sutures may not withstand a rigid erection. Therefore, prevention of erection and management of pain are extremely important following hypospadias repair, especially in adult patients. In this prospective study, we aimed to achieve these goals by using an epidural block with patient-controlled analgesia. We allocated 20 adult patients scheduled for hypospadias repair randomly either to receive or not to receive epidural analgesia. Postoperative pain was scored according to a standardised scoring system, based on a 10 point visual analogue scale. In group I (n = 10), analgesia was provided by a 3 ml h(-1) continuous infusion of fentanyl (2 microg) and bupivacaine solution (0.125%) in 1 ml saline via an epidural catheter for the first 3 days. Patient-controlled epidural analgesia was administered with an additional 5 ml of the same solution when the pain score was high (> 4). After 3 days, fentanyl was excluded from the treatment protocol, and analgesia was maintained with bupivacaine (0.125%). In group II (n = 10, control group), an epidural catheter was not inserted, and analgesia was maintained with pethidine (1 mg kg(-1)). Pain management was found to be more effective in group I. No erections occurred in group I, but the erection rate in group II was mean +/- s.d. = 1.7 +/- 0.2. The differences were found to be statistically significant (P<0.05). We highly recommend the technique described here, which offers efficient analgesia and control of erection in adult hypospadias patients.

Clonus: an unusual delayed neurological complication in electrical burn injury.

Patients surviving high-voltage electrical injury may have early and delayed sequelae. The most apparent neurological complications are known to be cerebral injury, spinal cord lesions, peripheral-nerve injuries and motor neuropathies. In this study, clonus, which is an unusual late neurological sequela in an electrical burn patient and presented as series of rhythmic, monophasic contractions and relaxations of a group of muscles, is presented. Possible mechanisms of this unusual late sequela and the clinical outcome of the patient are discussed. Ankle and patellar clonus was observed in 4 patients and uvular clonus in 1 patient. Clonus started 3 weeks following the injury in our patients and disappeared over a period of 1 yr in 2 patients, and did not disappear in the remaining 2 patients. In the current literature, this is the first report, which presents an unusual sequela following electrical injury. Clonus should also be considered a specific type of neurological sequela following high- or super-voltage electric injury. This may help to inform the patients in the postinjury period and to improve the efficacy of the rehabilitation of the victims.

Lower extremity salvage using a free flap associated with the Ilizarov method in patients with massive combat injuries.

Nine patients with massive combat injuries of the lower extremities were treated with Ilizarov bone transport in conjunction with free muscle flap coverage. In 4 patients soft-tissue coverage was applied first, and distraction osteogenesis was initiated 4 to 6 weeks later. In 3 patients both methods were applied simultaneously, and in 2 patients soft-tissue coverage occurred after distraction. The bones healed well, and all flaps survived. The segmental defects ranged from 8 to 16.5 cm in greatest dimension. The total disability time from initial injury ranged from 16 to 25.5 months. In all patients, full union of the tibia was achieved, and no osteomyelitis occurred. However, in 2 patients the applied flap became depressed, necessitating another flap operation. Despite late treatment in all 9 patients, successful results were obtained. Maintaining the original length of the tibia and providing timely, definitive treatment offer the best outcome for repair of massive injuries of the lower extremities. The Ilizarov transport method, used in combination with muscle flap coverage, represents an effective therapy for repair of massive injury of the lower extremities.

Results of artificial inflammation in scarless foetal wound healing: an experimental study in foetal lambs.

Recent experimental and clinical evidence suggests that the foetus responds to injury in a fashion fundamentally different from the adult. Foetal wound healing occurs without scar formation. The mechanisms causing this difference are still not well defined but absence of inflammation may play a significant role. The aim of this study was to investigate the effects of artificially induced inflammation on scarless foetal wound healing. Twelve time-dated pregnant ewes underwent hysterotomies at 70 and 90 days' gestation. A potent chemoattractant agent (N-formyl-methionyl-leucyl-phenylalanine) was injected into the upper lip of the foetus in the first operation. In the second operation, a full-thickness incisional wound on the right side and a 3-mm excisional wound on the left side of the upper lip were created and closed primarily. A control wound was created on the lower lip. Macroscopic and histologic examinations of the wounds after birth revealed visible scar lines on the upper-lip wounds but no scar line on the lower lip, and an increase in fibrous tissue and collagen content in the upper-lip wounds. We have shown that injecting a chemotactic agent can stimulate inflammation in a period of gestation when tissue injury can not. Although lack of inflammation due to tissue injury in the early period of foetal life may be an important cause of scarless healing, further experimental studies should be carried out to investigate the pathways that are not activated by tissue injury, the immune status of the foetus and the growth factors involved in the inflammatory response.

Measurement of orbital volume by a 3-dimensional software program: an experimental study.

PURPOSE: This study reports a simple method with high accuracy for determining orbital volume from computed tomography (CT) scans. MATERIALS AND METHODS: The volume of 20 orbits was evaluated in 20 dry skulls by use of a 3-dimensional software program in General Electric High-Speed Advantage CT/I (Milwaukee, WI), and compared with the volume obtained by direct measurement using the water displacement method. Accuracy of volume measurement by this software program was assessed statistically by paired samples t-test. RESULTS: The mean volume was found to be 28.37 mL +/- 2.15 by direct impression and 28.41 mL +/- 2.09 by the software program. Volume difference between the 2 methods averaged 0.93 +/- 1.08 mL for each orbit (P < .01). The correlation between the techniques was found to be high (r = 0.887, P < .01). There was no significant volume discrepancy between the 2 methods. CONCLUSION: Measurement by the technique described is an easy and accurate method of assessing the volume of the orbit.

Comparison of lymphocyte populations in cutaneous and electrical burn patients: a clinical study.

Immunosuppression following thermal injury has been noted in recent years. Both cellular and humoral immune systems have been reported to be affected. The present study aimed to compare the quantitative differences between cutaneous and electrical burn patients in respect to the partition and levels of lymphocyte populations. From March 1997 through February 1998, 15 patients with major thermal injury or high voltage electrical injury were included in this clinical prospective study. Blood samples were collected at three and seven days postburn. The evaluation of lymphocyte populations of patients was performed by SimulTest IMK plus. T cell and B cell populations, activated T cells, natural killer and helper T cell levels were all suppressed in both groups. Suppressor T cell levels were elevated in electrical burn group at both three and seven days. Therefore, CD 4/CD 8 ratios were more suppressed in electrical burn group. In conclusion, lymphocyte populations in electrical burn patients and also contributing factors which play important roles in the development of sepsis in both group need to be investigated further.

Supratrochlear artery flap for the repair of lower eyelid defects.

An island pattern flap in the treatment of lower eyelid cicatricial ectropion is described. The flap is based on the supratrochlear artery and its associated veins. The donor site can be closed easily primarily. The very thin thickness of the pedicle increases the rotational arc of the flap. However, this procedure requires two stages and there is a slight bulkiness of the flap, both of which are major drawbacks of this method. This flap was used to restore missing supporting soft tissue of the lower eyelid in the clinical cases described herein.

Effects of cerium nitrate bathing and prompt burn wound excision on IL-6 and TNF-alpha levels in burned rats.

The physiopathological events following thermal injury are not limited to the surface effects of heat but are also related to acute inflammatory reactions. Both tumour necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) are important mediators of the acute and severe inflammatory reaction in thermal injury. Surgical manipulation of the burn wound is known to prevent excessive release of cytokines. Cerium nitrate--a rare earth element--has been reported to have a protective effect against postburn immunosuppression. The aim of this study was to compare the effects of burn wound debridement and treatment with cerium nitrate bathing on the serum levels of TNF-alpha and IL-6 in rats. Treatment by cerium nitrate bathing prevented the elevation of TNF-alpha levels in the early period after thermal injury. The experimental study showed, as in other studies, that high levels of IL-6 appear to inhibit TNF-alpha elevation. High levels of IL-6 and, as a result, relatively low levels of TNF-alpha in the early period of thermal injury may limit the severity of the inflammatory reaction, which is caused by TNF, the most potent inflammatory cytokine. Since similar levels of IL-6 and TNF-alpha were achieved by both cerium nitrate bathing and burn wound debridement, cerium nitrate may be considered as equivalent to prompt excision of burn eschar.

Repair of high-energy-induced tissue defects of the dorsal foot by free muscle transfer and skin graft.

Various alternative methods have been used for repair of extensive dorsal foot defects due to high-energy-induced injuries. The authors reconstructed such defects with free muscle transfers and skin grafts in 9 male patients (average age, 21.7 years) between the years 1995 and 1998. Patients (right foot, 5; left foot, 4) presented with injuries due to military rifle gunshot (N = 4), mine explosion (N = 2), high-voltage electricity (N = 2), and traffic accident (N = 1). The patient injured in a traffic accident was treated with skin grafting only, and experienced osteomyelitis and skin breakdown. The other 8 patients were injured acutely and were hospitalized within 3 weeks of injury. After serial debridement of necrotic tissues, surgery was performed at an average of 6 weeks postinjury. Metatarsal bone defects of 5 cm in 3 patients were repaired by iliac (N = 2) and fibular (N = 1) bone grafts. Free muscle latissimus dorsi (N = 4) and rectus abdominis (N = 5) flaps were transferred microsurgically. The transferred muscle flaps were covered with split-thickness skin grafts. Mean operation duration was 5 hours 12 minutes. All flaps survived. The average area of soft-tissue defect repaired was 93 cm2 (range, 36-231 cm2). Average follow-up was 25 months. No symptoms of osteomyelitis and skin breakdown were encountered in the 8 acutely injured patients. Monofilament sensory tests revealed diminished protective sensation in 5 patients and absence of protective sensation in 4 patients. Partial resorption of bone grafts occurred in 2 patients. Thinning of the flaps was performed by tangential excision in 2 patients whose muscle flaps did not diminish in thickness. All patients were able to wear normal shoes. The authors suggest the use of free muscle transfer in reconstructing extensive soft-tissue defects of the dorsal foot.

Reconstruction of contour and anterior wall defects of frontal bone with a porous polyethylene implant.

Frontal bone contour defects cause marked facial deformity, which is instantly obvious to the observer. The aetiology is usually post-traumatic either following a traffic accident or a gunshot injury. The contour deformity of the frontal bone was reconstructed using Medpor porous polyethylene in 12 consecutive patients during a period of 2 years. In four of the patients, we used a coronal approach, whilst using the old incision scar and laceration for access in the remainder. In two of the patients it was not necessary to fix the implant at all, but the remainder were fixed with lag screws because of implant mobility. The aetiology, the technique used, and the results obtained are presented.

Reconstruction of foot defects due to mine explosion using muscle flaps.

Landmine explosions bring a formidable challenge to both patients and reconstructive surgeons. Free tissue transfer is the only method of repairing such extensive soft tissue defects of the foot after serial debridements. Sixty-five consecutive free muscle flap transfers were performed in 54 patients who had foot defects involving soft tissue and bone due to mine explosions. Although posttraumatic vessel disease had complicated most of the cases, overall flap survival rate was 83%. Each patient was ambulatory. Ulceration in long-term period was seen in only one patient. Eighty-five percent of patients with successful bone reconstruction and 41.6% of patients without adequate bone replacement demonstrated normal weightbearing in footprints and gait analysis. Free muscle flaps with split thickness skin graft and bone replacement are recommended for the reconstruction of such devastating wounds.

Reconstruction of saddle nose deformities using porous polyethylene implant.

Various materials have been employed for nasal contour restoration. We used porous polyethylene implants in reconstruction of saddle nose deformity in 36 cases. Only one complication occurred in the 8-18 months follow-up period. No implant was removed. Both cosmetic and functional results were accepted as pleasing by the patients.

Four limb amputations due to electrical burn caused by TV antenna contact with overhead electric cables.

A 22-year-old man who sustained four limb amputations due to an electrical burn caused by contact of a TV receiver antenna with overhead electric cables is presented. The indications for limb amputation and the necessary preventive measures for such injuries are discussed.

The last 10 years in a burn centre in Ankara, Turkey: an analysis of 5264 cases.

This is a retrospective study analysing 5264 patients treated in the burn centre at Gülhane Military Medical Academy from 1 January 1986 to 31 December 1995. Our burn centre is not only the first, but one of the best established and supported in Turkey. Our present study has the largest patient group of other previously published studies from Turkey. Of the total patients studied, 4464 patients had minor burns and were treated on an outpatient basis and 800 patients had moderate to major burns. Although our centre is in a military area in Ankara, only 1047 (20 per cent) patients were military personnel and the military-related burn causes comprised only 6 per cent of the total. The remaining 4217 (80 per cent of the total patients) were civilians. Flame injuries were also more frequent in military patients than civilians. Minor burns were most common in the age group 0-10 years old (40 per cent) and moderate to major burns in the age group 21-30 years (54 per cent). Scalds were the main cause of paediatric burns. Male patients were dominant. The overall mortality among inpatients was 18.2 per cent and mean total body surface area (TBSA) was 57.6 per cent in patients who died. 134 patients demonstrated inhalation injury and 82 per cent of these patients died. The epidemiological pattern of our patients is similar to that in other studies from developed countries, although some ethnic causative factors could be found. Our study indicates that emergency measures should be taken to prevent flame injuries at military barracks and industrial workplaces and scalding accidents to children at home and throughout the country.