Rhabdomyomatous mesenchymal hamartoma.

The authors report the case of a 6-month-old boy seen at Ankara Numune Hospital because of a papillomatous lesion centrally located on the chin. The lesion was excised under local anesthesia, and histologic examination revealed numerous eccrine glands and muscle bundles, neuronal tissues, and fatty tissue covered by stratified squamous epithelium. According to the histologic findings, the lesion was diagnosed as rhabdomyomatous mesenchymal hamartoma, which is known to be a rare lesion of childhood.

A different strategy in the surgical treatment of capsular contracture: leave capsule intact.

The authors present their experience with the surgical treatment of capsular contracture to achieve better results in a safe, predictable, and practical way, and discuss the possible treatment modalities. They simply advise leaving the capsule intact, even if it is calcified, and create another pocket, rarely in the front or, more typically, at the back of the capsule. If the breast tissue is also ptotic, a mastopexy procedure may be added to the procedure, in addition to augmentation, with a rather small prosthesis placed in the new pocket or, occasionally, in the old one. External, forceable massage is not advisable to treat the capsule. Open capsulotomy and/or partial capsulectomy can be applied to release the capsule. However, it is not advisable since recurrence is usually inevitable. The purpose of this paper is to present a series of surgical procedures to avoid the problems created by the capsule and present different cases with good results.

Infantile digital fibromatosis: an unusual localization.

Infantile digital fibromatosis (recurrent digital fibromatosis) is a rare, benign fibrous growth of childhood. The authors present a case of a 16-year-old child with an infantile digital fibromatosis on the volar surface of the right little finger at the distal interphalangeal joint level. After excision of the tumor, histopathologic diagnosis was shown to be infantile digital fibromatosis. The patient has been free of recurrence for 3 years after surgery.

Unsatisfactory results of periareolar mastopexy with or without augmentation and reduction mammoplasty: enlarged areola with flattened nipple.

A method of repair is described for correction of abnormally enlarged nipple-areola complex following both periareolar mastopexy and pregnancy. Although during periolar mastopexy or reduction mammoplasty regular subcuticular dermal sutures may control the enlargement of nipple-areola complexes initially, the periareolar scar becomes hypertrophic and areolar spreading occurs to some extent. Periareolar mastopexy techniques are indeed advisable only for minimal hypertrophies or ptosis of the breast, especially for areolar asymmetry, if an acceptable, normal-size areola is expected. The authors believe that in periolar mastopexy or reduction mammoplasty cases resulting in enlarged nipple-areola complexes, the size of the areola can also be corrected by reduction mammoplasty or mastopexy using vertical bipedicle techniques. Although surgery results in an inverted T incision, the shape of the breast is more acceptable and the size of the areola does not enlarge with time.

Which dressing for split-thickness skin graft donor sites?

There are a variety of methods used for the postoperative management of the donor site created after harvesting a split-thickness skin graft. The authors compare three major groups of dressings-open, semiopen, and closed-performed on 60 patients divided into three groups. These different dressings were compared based on healing time, quality of the regenerated skin, and patient comfort. Biopsy specimens were obtained from the donor sites of each group for the assessment of healing quality and stage. An ideal donor site dressing method is one that affords protection from dehydration and prevention of wound and infection while also achieving rapid and painless healing of the donor site. The closed-dressing group had the shortest healing time, shown both clinically and histologically, and superior patient comfort was also documented in this group. The closed-dressing group showed qualitatively superior healing when compared with open and semiopen donor sites. This was attributed to protection from dehydration and mechanical trauma, and avoidance of exogenous contamination.

"Pac Man" flap for closure of pressure sores.

The purpose of this study was to modify the classic bilateral V-Y advancement flap procedure to decrease the tension in its closure and to break the midline vertical scar by interdigitating the flaps. After debridement of a pressure sore, the V-Y flaps were marked on both sides of the wound. Skin incisions were carried down to the muscle fascia along the sides of the flaps. The upper and lower limbs of the V-shaped flaps were elevated as triangular flaps but remained attached to the main flap. The tip of the upper limb of one of the flaps was transposed into the defect and sutured to the contralateral V-Y flap at the midpoint of its concave side facing the defect. The lower limb of the contralateral flap was then transposed into the defect and sutured to the first V-Y flap. To complete the interdigitated closure, the lower limb of the first flap was sutured below the contralateral flap, and the upper limb of the contralateral flap was sutured above the first flap. The final view of the flaps was similar to "Pac Man," so the authors decided to call this flap the Pac Man flap. The flaps healed well in all patients, and wound breakdown or recurrence of the pressure sore was not observed during the 3 to 14-month follow-up.

Bilateral, extended V-Y advancement flap.

A modification of the V-Y advancement flap for the closure of circular skin defects is presented to decrease the tension in the closure and to break the midline vertical scar. Bilateral, extended V-Y advancement flaps with additional limbs extending to the advancing edges of the standard flaps were marked on both sides of the wound. After advancement of the V-Y flaps on their subcutaneous pedicle, the upper and lower extensions were hinged downward as transposition flaps to close the middle portion of the circular defect, where maximum tension occurs. This procedure was applied to 10 patients with sacral and trochanteric pressure sores. No complications or recurrences were noted during the 2 to 10 months of follow-up. Bilateral, extended V-Y advancement flaps enable the reconstruction of large defects without midline tension. Also, the resulting scar where the flaps meet is a zigzag line, so a straight midline scar is avoided.

Innervated dorsal adipofascial turnover flap for fingertip amputations.

Traumatic or thermal injury to the fingertip may result in composite tissue loss. Exposed tendon, bone, or joint surface is best treated by flap coverage. The authors present their experience with a new technique that provides coverage for fingertip defects using the innervated dorsal adipofascial turnover flap, which consists of adipofascial tissue only and relies on the arterial anastomotic network of this tissue layer to sustain its vascularization. Eight digital amputations between the distal phalanx proximal to the nail matrix and midportion of the middle phalanx were resurfaced successfully with the innervated dorsal adipofascial turnover flap. The flaps survived completely; the mean follow-up was 9 months. This technique seems to be a relatively simple way of achieving early recovery. It does not require the use of distant flap immobilization of adjacent digits, nor does it require the use of homodigital flaps, which may jeopardize an already injured finger. The main advantages of the innervated dorsal adipofascial turnover flap are its ready availability from the local tissue, its sensation, and the absence of functional and aesthetic disturbance at the donor site.

Phenotypic variability of triphalangeal thumb-polysyndactyly syndrome linked to chromosome 7q36.

Triphalangeal thumb-polysyndactyly (TPT-PS) is an isolated limb malformation consisting of pre- and postaxial polysyndactyly of hands and feet. The only family reported so far is of Dutch origin, and the genetic mapping study localized the TPT-PS locus at chromosome region 7q36 where the isolated triphalangeal thumb (TPT) anomaly has also been mapped. It was suggested that TPT-PS is a phenotypic variation of isolated TPT, and the same ancestral mutation may produce both phenotypes. Here we report on the second family with this malformation from the Turkish population. The characteristic findings in this family are triphalangeal thumb, webbing between 3rd, 4th, and 5th fingers associated with bony synostosis in the distal phalanges of the same fingers, and pre- and postaxial polysyndactyly of feet. Some individuals show a more severe phenotype with a complete syndactyly of all fingers giving a "cup-like" appearance to the hands. Genetic linkage study with DNA markers D7S1823, D7S550, D7S559, and D7S2423 demonstrated that this family is also linked to chromosome band 7q36. Identification of a second family from a distinct ethnic background suggests that TPT-PS and isolated TPT are not caused by the same ancestral mutation as it was originally anticipated.

Dorsal adipofascial turn-over flap for fingertip amputations.

We designed a dorsal adipofascial pedicled flap to cover amputations of the tip of the same digit. This flap includes all the adipofascial tissues from the dermis to the paratenon of the extensor tendons. After elevation of the skin, the adipofascial tissues are raised as a flap and turned over to resurface the exposed bone or joint and then covered with a split thickness skin graft. Ten digital amputations between the distal phalanx proximal to the nail matrix and the mid portion of the middle phalanx were successfully resurfaced with dorsal adipofascial turn-over flaps. All flaps survived completely and the mean follow-up was 11 months. This one-step procedure would seem to be a relatively simple way of achieving early recovery because it does not require the use of distant flaps immobilization of adjacent digits, or homodigital flaps that might jeopardize an already injured finger.

Tangentially split gluteus maximus myocutaneous island flap based on perforator arteries for the reconstruction of pressure sores.

From 1995 to 1997, the authors used tangentially split gluteus maximus myocutaneous island flaps based on the musculocutaneous perforator arteries for the reconstruction of pressure sores located in the trochanteric, sacral, and ischial regions of 30 ambulatory and paraplegic patients. The postoperative follow-up period was 18 months. Postoperative electromyograms were performed on the ambulatory patients to compare the function of the gluteus maximus muscles on each side. There were one major and two minor postoperative complications. There was no total flap loss. The major advantage of this technique is the preservation of most of the gluteus maximus for stair climbing and single-limb support in the ambulatory patient. The tangentially split gluteus maximus myocutaneous island flap is recommended as the procedure of choice for closure of sacral, ischial, and trochanteric ulcers in both the ambulatory and nonambulatory patient.

Prophylactic antibiotics in plastic and reconstructive surgery.

There is no consensus in the literature on the use of prophylactic antibiotics to prevent postoperative infection. This study was performed to investigate whether the use of prophylactic antibiotics has an effect on postoperative infection rates. A total of 1400 patients were classified into four groups based on their diagnosis. During the induction of anesthesia, half of each group received 2 g of a sulbactam-ampicillin combination and the other half received a placebo (saline solution) intravenously. Wound infection rates were observed in the postoperative period. Age, sex, and operative site of the patients with the same diagnosis were comparable in each group. The white blood cell count and the body temperature reading of each patient were recorded postoperatively. Wounds were observed daily in the postoperative period and graded according to a predetermined scale. Bacteriologic specimens were obtained from patients who had wound infections. According to our clinical experience, antibiotic prophylaxis is not necessary in plastic surgery. At the end of our 6-year study, a significant difference could not be found between the antibiotic prophylaxis and placebo groups.

Reconstruction of mandible with fibula free flap.

The fibula can be used as a donor for a free flap for mandible reconstruction. It has the advantages of low donor site morbidity, consistent shape, ample length, and distant location to enable a two-team approach, allowing multiple osteotomies because of its periosteal circulation. It can be raised with a skin island for composite tissue reconstruction. Eight segmental mandibular defects (average 11.62 cm) were reconstructed following resection for tumour. Six defects consisted of bone alone and the other two had only a small amount of associated intraoral soft-tissue loss. Two patients underwent primary reconstruction. We performed two or three osteotomies on each graft and used miniplates and wires for bone fixation. The flaps survived in all patients. All osteotomy sites healed primarily. The aesthetic result of reconstruction was satisfactory.