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.

Ethyl pyruvate improves skin flap survival after ischaemia reperfusion injury.

BACKGROUND & OBJECTIVES: Reperfusion after ischaemia is detrimental to the tissues. The oxidative stress created and cytokines released are mostly responsible in this process. In this study, ethyl pyruvate, a known agent for its anti-inflammatory and antioxidant properties, was used to investigate the effects on ischaemia/reperfusion injury on skin island flaps in rats. METHODS: Sixty rats were randomly distributed in three groups (non-ischaemic, ischaemic and medication groups). Ethyl pyruvate was administered in the medication group with a dose of 50 mg/kg. After 24 h and one week, the animals were sacrificed, and the flaps were analyzed macroscopically, histopathologically, biochemically (total nitrite, malondialdehyde and myeloperoxidase). RESULTS: Biochemical markers indicating oxidative stress, were found elevated in ischaemic group, whereas medication with ethyl pyruvate significantly reduced these values. There was a significant reduction (P<0.05) in the levels of these markers between ischaemic and medication groups. Ethyl pyruvate improved all the parameters significantly. INTERPRETATION & CONCLUSION: Ethyl pyruvate showed strong scavenger activity against reactive oxygen species. It could be a potential candidate to improve the flap viability in reconstructive microsurgery, especially in free tissue transfers. However, more studies are warranted in experimental models to confirm these findings.

Asymmetric Z-plasty for telephone deformity in prominent ear correction.

There have been plenty of surgical techniques for the correction of prominent ears. "Telephone deformity" or "reverse telephone ear" has been described as the undesired result of the inappropriate correction of the prominent ear, mainly the deficient correction of the lobule. We have performed an asymmetric Z-plasty to the lobule to overcome this deformity not only by excision of the excess skin but also by transposition of the soft tissue. Between 2005 and 2011, the technique currently described was performed in 19 patients. Preoperative, intraoperative, and postoperative standardized photographs were taken, and measurements were done on postoperative first week, first month, and first year. The measurements include ear height at 3 different horizontal planes as follows: (1) the most cranial point of the ear, (2) the middle point of the ear, and (3) the most caudal point of the ear. The angle between the vertical plane of the head and the ear was measured at these previously defined 3 points. These measurements were used for indication and preoperative planning. There were statistically significant differences between preoperative and postoperative values (P < 0.05). The postoperative first year results indicated the effectiveness of this alternative technique for the long-term maintenance of the position of the lobule.

Tadalafil significantly reduces ischemia reperfusion injury in skin island flaps.

INTRODUCTION: Numerous pharmacological agents have been used to enhance the viability of flaps. Ischemia reperfusion (I/R) injury is an unwanted, sometimes devastating complication in reconstructive microsurgery. Tadalafil, a specific inhibitor of phosphodiesterase type 5 is mainly used for erectile dysfunction, and acts on vascular smooth muscles, platelets and leukocytes. Herein, the protective and therapeutical effect of tadalafil in I/R injury in rat skin flap model is evaluated. MATERIALS AND METHODS: Sixty epigastric island flaps were used to create I/R model in 60 Wistar rats (non-ischemic group, ischemic group, medication group). Biochemical markers including total nitrite, malondialdehyde (MDA) and myeloperoxidase (MPO) were analysed. Necrosis rates were calculated and histopathologic evaluation was carried out. RESULTS: MDA, MPO and total nitrite values were found elevated in the ischemic group, however there was an evident drop in the medication group. Histological results revealed that early inflammatory findings (oedema, neutrophil infiltration, necrosis rate) were observed lower with tadalafil administration. Moreover, statistical significance (P < 0.05) was recorded. CONCLUSIONS: We conclude that tadalafil has beneficial effects on epigastric island flaps against I/R injury.

Case series of topical and orally administered ß-glucan for the treatment of diabetic wounds: clinical study.

BACKGROUND: Chronic, nonhealing wounds, foot ulcers, and lower extremity amputations are among the most problematic complications associated with diabetes mellitus. Standard care for diabetes-related chronic ulcers has included treatment of infection, weight off-loading, aggressive surgical débridement, and maintenance of a moist wound environment with frequent dressing changes. OBJECTIVE: Yeast glucan is a particular high-molecular-weight polymer of ß-(1,3)-glycosidic linkages of glycopyranose. We report our observations about the effectiveness of topically and orally administrated ß-(1,3)-glucan for the treatment of chronic diabetic wounds and compare them to the literature results previously reported for similar wounds. MATERIALS AND METHODS: Twenty-two patients with nonhealing ulcers associated with diabetes were included in this study. ß-Glucan was given both orally and topically for the treatment of nonhealing ulcers. Macroscopic changes and surface areas of diabetic ulcers were recorded, and complete healing times were noted for each patient. RESULTS: A rapid decrease in size and healthy granulation were significantly observed in most patients. The duration of complete healing averaged 10.8 weeks (range 6-20 weeks). No adverse events were observed in the treatment period. The complete healing time was shorter than the results previously reported in the literature. CONCLUSIONS: Our observations support the view that application of glucan hastens epithelialization and wound closure, so topically and orally administered ß-(1,3)-glucan therapy can help reverse some of the deficits in impaired healing diseases such as diabetes mellitus.

Scintigraphic and tomographic evaluation of biological activities of prefabricated free and vascularized bone allografts.

BACKGROUND: We performed an experimental study on rabbits to compare the biologic activities of free and vascularized cortical and corticocancellous solvent-dehydrated bone allografts by scintigraphy and three-dimensional computed tomography (CT). METHODS: Twenty New Zealand white rabbits (2500-3000 g) were divided into 2 groups each consisting 10 animals. In group 1, solvent-dehydrated human cadaveric cranium allografts (corticocancellous bone) were used. The grafts were divided into 20 pieces, approximately 10 × 10 × 5 mm. On the right ears, grafts were placed on dissected vascular bundles. On their left ears, allografts were implanted into subcutaneous pockets without dissecting any vascular bundle. The same procedure was performed in group 2 with solvent-dehydrated human cadaveric fibula bone allografts (cortical bone). No infection or any animal death occurred during 12 months of observation. At the end of the 12th month, implanted bone allografts were evaluated by 3-phase bone scintigraphy to observe the circulation and viability of the grafts and three-dimensional CT scans to measure their dimensions. RESULTS: Radioactive uptake by scintigraphy of grafts placed on vascular bundle was higher than grafts placed in pockets. t-Test was calculated for region of interest of right ear (vascularized) to left ear rate (nonvascularized) according to graft type. Rate for corticocancellous bone graft was 1.187 ± 0.179 (P = 0.038) and cortical bone graft was 1.055 ± 0.052 (P = 0.038). There was correlation between region of interest generated from arm and neck regions and graft regions (P = 0.001). Regarding the dimension measurement made by three-dimensional CT, all the grafts grew whether they were on vascular bundle or not. Mann-Whitney test was used to determine whether differences between preoperative and postoperative volumes of grafts and growth of all grafts were significant (P = 0.007 for vascularized cortical bone and P = 0.005 for others). Kolmogorov-Smirnov test was performed to evaluate the distribution of growth rate. Vascularized medullar-cortical and nonvascularized medullar bone grafts expanded more than nonvascularized cortical bone (P = 0.001, P = 0.005, P = 0.001, respectively). CONCLUSIONS: Vascularized bone allograft combines the advantages of autogenous and allogenous grafts. Both scintigraphic and tomographic results overlapped that corticocancellous and cortical bones developed more on vascular bundle. Even though radioactive uptake was statistically higher in vascularized bone allografts, we determined that this small difference did not affect the overall late vascularity of the bone allografts. In conclusion, regardless their types or placement on vascular bundle, prefabricated bone allografts had similar metabolic function after 1 year of integration.

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.

Bilateral extraoral, infraorbital nerve block for postoperative pain relief after cleft lip repair in pediatric patients: a randomized, double-blind controlled study.

The objective of this study was to evaluate the effectiveness of bilateral extraoral infraorbital nerve block with 0.25% bupivacaine administered at the end of surgery in postoperative pain relief after cleft lip repair. Forty ASA I-II children were randomly divided into 2 groups. Group I received 1.5 mL 0.25% bupivacaine and group II received 1.5 mL saline. FLACC scores of the patients in the recovery room in group I were 4 times less than in group II (P = 0.001) and in the first 4 hours postoperatively were apparently less in group I (P = 0.001). Mean time to first paracetamol requirement was longer in group I (P = 0.001). Total paracetamol consumption was lower in group I (P = 0.001). None of the patients required rescue tramadol in group I, whereas all patients in group II needed. In group I, parent satisfaction scores were higher (P = 0.001). Vomiting incidence was higher in group II (P = 0.028). Bilateral extraoral, infraorbital nerve block administered at the end of surgery provides satisfactory analgesia with high parental satisfaction and lower complication rates and reduces rescue analgesic consumption in patients undergoing repair of cleft lip.

"Lid technique": cyanoacrylate-assisted anastomosis of small-sized vessels.

This paper presents the details of an experimental study of arterial anastomosis, combining suture with the cyanoacrylate tissue adhesive. At the distal end of the vessel, two parallel incisions were made, 180 degrees apart from each other, and two sutures were placed passing from the proximal end to exit from the most distal part of the longitudinal incisions. The tissue adhesive was then applied to the proximal vessel, and the full-thickness vascular 'lid' flap was closed over it on anterior and posterior surfaces. Eighty anastomoses were carried out at the left and the right femoral arteries of 40 Wistar rats. For all of the animals, conventional end-to-end anastomosis was carried out on the left side, and the lid technique was used on the right side. There was no statistically significant difference between the patency rates of the groups (two non-patent in control and two in the study group) (P>0.05), whereas significantly reduced operation time (mean 16.2 and 10.7 min in control and study groups, respectively) (P<0.0001) and bleeding time (median 1.5 and 0.5 min in control and study groups, respectively) (P<0.0001) were documented in the study group. Histopathological evaluation of both the patent and non-patent vessels at day 21 revealed no signs of tissue toxicity or intraluminal adhesive leakage. In view of these data, it was concluded that the technique provides an effective and simple method for end-to-end anastomosis of small-calibre arteries.

Dealing with the venous congestion of free flaps: venous catheterization.

For head and neck reconstruction after tumor ablation surgery, free flaps are mostly the chosen treatment modality for most of the centers. Coping with venous insufficiency and increasing venous outflow of the flap during this process increases the success rate. To increase venous outflow, triple-lumen central venous catheter is inserted to one of the donor veins of the flap that has venous insufficiency and one intact vein anastomosis.

Manually adjustable conformer for socket reconstruction: a practical and simple method.

Loss of an eye can be a traumatic experience for a patient. The subsequent formation of scar tissue prevents the performance of daily function and, more important, is accompanied by social isolation. To ensure a permanent prosthesis, appropriate closure of the socket is proposed. A conformer is a good method to carry out such a closure. We propose a manually adjustable conformer for the socket reconstruction that is specially used for the first time for this purpose.

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.

Maxillary sinus lipoma: an unanticipated diagnosis.

Subcutaneous tissue gives rise to numerous lesions such as lipoma, the most common benign soft tissue tumors. Lipoma is seen only extremely rarely in osseous units. In addition, craniofacial involvement of intraosseous lipoma may be misdiagnosed as a fibroosseous tumour such as fibrous dysplasia. Here, we present a case of an intraosseous lipoma obviously destroying and invading the maxillary bone.

Struggling with ischemia reperfusion injury.

Ischemia reperfusion (I/R) injury is a complicated injury that compels either the patient or the practitioner. In the literature, there still is a debate over how to manage the injury. Typically, no single treatment is feasible. So far, numerous substances have been used as treatments and the majority of these are antioxidants. In this article, a combined therapy is implemented for a patient suffering from I/R injury.

Prevention of tendon adhesions by the reconstruction of the tendon sheath with solvent dehydrated bovine pericard: An experimental study.

BACKGROUND: The achievement of the kinetic functions of a finger in full range of motion after the injury and the repair of the flexor tendon has been a challenging issue in hand surgery. Several current studies emphasize the importance of the tendon sheath for the healing of the tendon and for the prevention of the adhesive bands and advise primary repair or reconstruction of them. Various biological and synthetic materials have been used for this purpose with different rates of success. METHODS: In this experimental study, the sheaths of flexor tendons of chicken toe were excised and three groups were observed: group 1, primary sheath not repaired; group 2, sheath repair with autogenous fascia; and group 3, sheath reconstruction with solvent dehydrated bovine pericardium (SDBP). RESULTS: Histopathologic evaluations were performed on the 3rd and 12th weeks to determine the outcome of the repair methods regarding the gliding surfaces of the tendons, adhesion rates, and inflammatory reactions, which are the main issues on the healing of the tendon. The results indicated less formation of adhesions in group 3 compared with groups 1 and 2 (p = 0.001). CONCLUSION: The results showed that SDBP can be used for the reconstruction of the sheaths successively for the prevention of the adhesive bands in flexor tendon surgery.

Evaluation and management of exposed high-density porous polyethylene implants: an experimental study.

Numerous autogenous and alloplastic materials have been used for restoration of contour deformities of the face. Alloplastic materials have come into use to replace autogeneous bone grafts because bone grafts are associated with donor site morbidity, resorption and difficulty in shaping. Porous high-density polyethylene (HDPPE) is a commercial product which is nonallergenic, nonantigenic, noncarcinogenic and nonresorbable, highly stable and somewhat flexible. It has pores of 125-250 mum which enable tissue ingrowth resulting in firm attachment and integration of the implant to the surrounding tissues. In this study we aimed to evaluate the fate of the exposed implants and proposed a method to manage the exposed medpor implants. Twenty rats were used for this experimental study. Three phases involving the implantation, exposition, and the closure of the implants were held respectively. Closure was performed in two groups: 1) After perforating the exposed implants; 2) Without perforating the exposed implants. No serious complications were seen. Perforated exposed implants when covered with flaps rather than grafts could be covered. Exposed implants were not covered easily as indicated by the previous studies. This study demonstrates that early closure of perforated implants with flaps can give the best clinical results when exposed implants are covered in a short period after exposition so that the ingrown fibrous tissues are still intact. We believe that grafting of the exposed medpor implants cannot be effective either in early or late period. Perforating the exposed implants yield successful results as ingrowth of the tissues are enabled.

An alternative technique for microsurgically unreplantable fingertip amputations.

Reattachment of the amputated fingertips as composite grafts has been performed for distal levels in children, with high rates of good outcome, but the majority of the reports emphasized that this procedure had success rates only up to 50% in adults. Several techniques to enhance composite graft take in adults have been defined. In this study, a technique to enhance nonmicrosurgical replantation of amputated fingertips as composite grafts is presented.Twenty-three patients were treated with this technique, 20 of which were adults. An area of skin on the amputation margin of the stump was deepithelized, and the amputated part was defatted to reattach the piece as a cap composite graft and to increase the contact area. The patients were evaluated after the operations regarding functional and esthetic outcome. Success rates of 86.95% in total and 85% in adults were achieved, with acceptable sensibility (with a mean value of 7.26 mm for the 2-point discrimination), minimal shortening (a mean value of 6.80 mm), and satisfactory esthetic outcome using this technique.

Pull-in suture technique for the treatment of mallet finger.

BACKGROUND: Mallet finger deformity is a common disability that causes discomfort and inconvenience to the patient. Although numerous operative techniques have been described, surgical management remains controversial. METHODS: Between 2002 and 2004, 19 patients with an unsuccessful splinting regimen history, chronic deformities of tendinous origin (>3 months after the injury), or fractures involving 30 percent or more of the articular surface underwent surgical treatment. In 11 patients, chronic mallet finger deformity with tendinous origin was present, whereas eight patients presented with mallet fractures involving more than 30 percent of the articular surface. Open reduction with internal "pull-in" sutures and distal interphalangeal joint immobilization with Kirschner wire was accomplished. Active motions of the proximal interphalangeal and metacarpophalangeal joints were not restricted. After removal of the Kirschner wire at week 6, active flexion exercises were commenced immediately, and daily activities were not restricted. Full activity was allowed at day 7. Goniometric measurements, radiographs, and patient satisfaction were evaluated during the follow-up period. RESULTS: The mean follow-up period of the patients was 16 months (range, 4 to 28 months). Mean extensor lag of the distal interphalangeal joint was 2 degrees (range, 0 to 6 degrees). The mean flexion of the distal interphalangeal joint was 74 degrees (range, 60 to 90 degrees). According to Crawford's evaluation criteria, 14 excellent and five good results were obtained. Apart from radiologically documented mild degenerative changes or joint narrowing in six patients, no complication was encountered. CONCLUSION: The pull-in technique allows accurate realignment of the tendon-bone unit without any specific instrumentation or intraoperative fluoroscopic imaging methods.