Salvage of Exposed Cardiac Implants Using Fasciocutaneous Rotation Flaps.

INTRODUCTION: Implantation rates of cardiac implantable electrophysiological devices (CIEDs) are rising, mainly because of the expansion of implantable cardioverter-defibrillators indications for primary prevention. As the CIED usage increases, CIED-related complications are also in rise. Transvenous approach and laser utilization techniques are replacing the open heart surgeries, for removal of CIED systems that are suspected to be infected. In this study, we aimed to share our new method of fasciocutaneous flap coverage results of patients with exposed CIED systems who were not eligible for the CIED replacement surgery for various reasons. PATIENTS AND METHODS: Patients operated with rotational fasciocutaneous flaps with addition of pectoralis fascia, owing to their exposed CIEDs between June 2016 and January 2019, were enlisted. Patients with signs of infection whether systemic or limited to the CIED pocket with or without positive blood cultures were referred to infectious diseases department and not included in this study. Patients included in the study were evaluated retrospectively in terms of demographic data, implanted CIED type, time elapsed from implantation to exposure, from referral to flap coverage operation, total follow-up time, survival ratios during follow-up, and complications related to flap coverage operation. In addition, indications for CIED implantation, patient comorbidities, and culture results obtained from the capsule encompassing the CIED battery unit were included to the evaluation. RESULTS: A total of 13 patients with exposed CIEDs have undergone total capsulectomy and CIED system coverage with rotational fasciocutaneous flaps. The mean patient age ± SD was 60.2 ± 13.4 years. The average time elapsed from CIED implantation to exposure was 27.3 ± 15.4 months. The average time spanned from initial referral to operation was 6 ± 1.6 days. The most prevalent comorbidity was diabetes mellitus. The average time elapsed during operation for pectoral fascia incorporated rotation flaps was 90 ± 10.6 minutes. Coagulase negative staphylococci were the dominant species (46.5%) obtained from capsule cultures. Apart from 1 case of hematoma, no early or late operation-related complication was encountered. CONCLUSIONS: A more precise definition of contamination and infection has to be made in guidelines, which may lead the first group to be treated without extraction. Surgical method defined in this study can be used for the treatment of patients in contaminated CIED subgroup, conserving individuals from risks of device extraction.

Evaluation of Neurotized Hypothenar Free Perforator Flaps Used for Fingertip Reconstruction.

INTRODUCTION: In reconstruction of digital amputations of the upper extremity, composite tissue alternatives with similar features are limited for finger tip reconstruction. Among these alternatives, free perforator flaps elevated from the hypothenar region (HFPFs) are defined, but reluctancy goes on for utilization of these flaps.In this study, we aimed to highlight the sensory results of HFPFs when a neural repair is incorporated to the flap and also to justify their usage by presenting functional and aesthetic outcomes of the reconstructions performed with HFPFs. METHODS: This clinical study was conducted from June 2015 to June 2017. Twelve patients with acute finger tip amputations were examined. Distal amputation levels were subgrouped according to Ishikawa classification. Patient demographics and amputation etiology were listed. All fingertip defects were reconstructed with a neurotized HFPF. All perforator anastomoses were performed in an end-to-end fashion. During follow-up, 2-point discrimination and dynamometric test were conducted. In addition, the Michigan Hand Outcomes Questionnaire was carried out. Evaluation of the results from a cosmetic standpoint was also conducted, with 4 blinded, independent surgeons using the visual analog scale. RESULTS: Of 12 digital amputations reconstructed with neurotized HFPFs, 10 were totally viable during follow-up, whereas partial loss was observed in 2 flaps. The mean age was 38.8 ± 11.8 years. Most of the amputations were classified as Ishikawa subgroup 2 (50%). The mean dynamic 2-point discrimination was 3.2 ± 0.11 mm and slightly greater compared with contralateral digit (P = 0.003). Also minor decreases were measured in forced grip and pulp-to-pulp grip strengths (P = 0.003). Overall satisfaction was 92.7% in Michigan Hand Outcomes Questionnaire. Average visual analog scale score was 7.25 out of 10. CONCLUSIONS: Hypothenar free perforator flaps, with incorporation of neural repair, give promising results for reconstruction of the fingertip. In addition to superior sensorial outcomes, HFPFs yield satisfying results from aesthetic and functional perspectives.

Comparison of venous repair results using either arterial or vein grafts in a crush-avulsion injury model

Background/aim: Venous insufficiency after replantation or revascularization is one of the most common causes of limb loss in either the short or the long term. The aim of this study was to evaluate the results of a new technique to overcome venous insufficiency. Materials and Methods: A crush-avulsion type of injury was formed in the femoral veins of rats of 3 separate groups. In the control group, primary repair was applied to the damaged veins and the remaining 2 groups were repaired with either an arterial graft or a vein graft. The success rates of anastomosis were then compared. Results: In the control group the patency rate was 25% in the 2nd hour, 12.5% on the 2nd day, and 12.5% on the 10th day. The patency rate in the vein group was 87.5% in the 2nd hour, 50% on the 2nd day, and 37.5% on the 10th day, whereas the patency rates in the artery group were 100% in the 2nd hour, 87.5% on the 2nd day, and 75% on the 10th day. Conclusion: Microsurgery requires experience and patience. It can be considered that the use of arterial grafts for venous repair in replantation after crush-avulsion type amputations can increase the success rate of replantation.

Beneficial effects of turnover orbicularis oculi muscle suspension flap for treating facial fractures via subciliary incision.

In patients with moderate lower lid laxity, the lower orbicularis oculi muscle becomes atonic or ptotic. Hence, in such patient populations, with periorbital fractures, additional vertical support endorsement either by lateral canthopexy or orbicularis oculi muscle suspension flap must accompany plate and screw fixations. In this report, we shared our experience in applying prophylactic suspension to the lower lid with turnover orbicularis oculi transposition muscle flap in zygomatic fractures treated by subciliary approach in 98 patients. Our results show that turnover orbicularis oculi muscle suspension flap avoids the rounding of the lateral canthal angle more successfully and prevents ectropion better than the resuspension orbicularis oculi muscle flap does. We advocate using this flap where zygomatic fractures are approached via the subciliary incision. We foresee that it is a reliable and easily executed technique especially in middle-aged patients with moderate lower lid laxity for the prevention of ectropion.

Salvage of the Exposed Cardiac Pacemakers With Fasciocutaneous Local Flaps.

OBJECTIVES: This study aims to investigate the efficacy of salvage of the mechanically exposed cardiac pacemakers with fasciocutaneous local flaps in elderly patients. METHODS: Between January 2014 and January 2018, ten patients (six females, four males; mean age 66.2 years) who were treated due to pacemaker exposition were retrospectively analyzed in this study. Exposed pacemaker and the wires were dissected, and capsulectomy was performed. The expose pacemaker was covered with the fascioutaneous flap. RESULTS: Only one patient had hematoma formation at early stage and revision was performed. All patients were treated successfully. No complication was observed during the follow-up period. CONCLUSION: Reconstruction with fasciocutaneous local flaps is an effective treatment modality in case of mechanically cardiac pacemaker expositions in elderly patients.

Neutrophil Elastase Inhibitor Increases Flap Survival in Experimental Degloving Injuries.

OBJECTIVES: Degloving hand injuries have generally been viewed as among the most difficult of injuries to manage due to the extensive nature of associated damage. The traditional approach to the circumferentially degloved segment of problematic flap viability has been to resuture the flap and to wait and see. However, the waiting period or the specific hemorheological protocol remains uncertain. This study aims to acknowledge if Sivelestat, known to ameliorate ischemia-reperfusion injury, enhances the survival of avulsed flaps in a hind limb degloving model of rats and to compare Sivelestat's effects to Pentoxifylline. METHODS: In this study, total flap area (cm2), area of necrosis in the flap (cm2), and the ratio between the necrotic and total areas (percentage) were determined. Angiogenesis among the groups was documented with CD31, anti-PECAM staining. TUNEL assay was performed to allow the visualization of cell nuclei containing fragmented DNA, a typical feature of apoptosis. RESULTS: The findings obtained in this study showed that Sivelestat administered at 10 mg/kg/hour dosage will inhibit the ischemia-reperfusion injury more pertinently than Pentoxifylline, which exerts only hemorheological effects. CONCLUSION: The anti-inflammatory effects of Sivelestat will be beneficial for decreasing the early complications of degloving injury, such as inflammation, sepsis, and edema, better than Pentoxifylline, which exerts only hemorheological effects.

Perforator artery repair in revascularization of extremity degloving injuries.

INTRODUCTION: This article aims to expand the microsurgical treatment options for extremity degloving injuries with perforator artery repairs of the specific degloved angiosomes in upper and lower extremity. METHODS: Fourteen perforator arteries were repaired in seven patients. Four of them had circumferential degloving and 3 of them have non circumferential degloving injury. All had repair of the perforator arteries of the specific degloved segments. Four patients had additional vein repairs but none of the patients had AV shunts. RESULTS: All perforators provided adequate arterial supply to their specific angiosomes with some necrotic areas in neighboring angiosomes. CONCLUSIONS: Perforator artery repair within the degloved tissues provides a direct arterial supply successfully even if one could not find an intact venous plexus.

Posterior Arm Perforator Flap for Axillary Reconstruction After Hidradenitis Suppurativa Excision.

INTRODUCTION: Hidradenitis suppurativa (HS) is a chronic inflammatory disease arising from the hair follicles in apocrine gland-rich areas. It is also one of the most common indications for axillary surgery. Reconstruction of the axillary region after such surgery must be performed meticulously due to its critical location and crucial content. In this report, we present our experience of reconstruction of axillary defects with posterior arm perforator flaps (PAPF) following radical excisions. METHODS: A total of 14 patients (9 male, 5 female) aged between 16 and 49 years who had presented with HS in the axillary region and, after surgery, underwent reconstruction with either island or skin bridge posterior arm flap between January 2015 and October 2016 were included in the study and evaluated retrospectively. All of the defects were reconstructed with PAPF following wide excision. RESULTS: Five of the flaps (over 4 patients) were designed as flaps with skin bridges, while the remaining 12 flaps in 11 patients were raised as island flaps. The flaps had areas ranging from 20 to 84 cm2 (mean 39.5 cm2), depending on the size of the defect after excision. The mean follow-up time after the operation was 6 months. Wound dehiscence was detected in one patient, and another patient developed marginal necrosis during the postoperative period; no other complications were observed. CONCLUSION: Posterior arm perforator flaps can provide sufficient amounts of soft tissue to cover axillary defects and should be considered as the flap of choice in axillary reconstruction.

INTRODUCTION: La maladie de Verneuil (MV), ou hidrosadénite suppurée, est une maladie inflammatoire chronique qui touche les follicules pileux situés près des glandes apocrines. C'est également l'une des indications les plus courantes de chirurgie axillaire. Il faut procéder à une reconstruction méticuleuse de la région axillaire après l'opération en raison de son emplacement difficile et de son contenu crucial. Dans le présent rapport, les auteurs présentent leur expérience de reconstruction des anomalies axillaires à l'aide de lambeaux perforants du bras postérieur (LPBP) après des excisions radicales. MÉTHODOLOGIE: Au total, 14 patients (neuf hommes, cinq femmes) de 16 à 49 ans atteints d'une MV dans la région axillaire qui ont subi une reconstruction par lambeau en îlots ou par pont cutané prélevé sur le bras postérieur entre janvier 2015 et octobre 2016 ont participé à l'étude et fait l'objet d'une évaluation rétrospective. Les chirurgiens ont reconstruit toutes les anomalies à l'aide de LPBP après une large excision. RÉSULTATS: Cinq des lambeaux (sur quatre patients) étaient sous forme de ponts cutanés, et les 12 autres (sur 11 patients) ont été prélevés en îlots. Les lambeaux étaient d'une taille de 20 à 84 cm2 (moyenne de 39,5 cm2), en fonction de la dimension de l'anomalie après l'excision. Le suivi moyen était d'une durée de six mois après l'opération. Un patient a présenté une déhiscence de la plaie et un autre, une nécrose marginale pendant la période postopératoire. Aucune autre complication n'a été observée. CONCLUSION: Le LPBP peut fournir une quantité suffisante de tissus mous pour couvrir les anomalies axillaires. Il faut le considérer comme le lambeau de première intention lors d'une reconstruction axillaire.

Utilization of arterial grafts in foot replantation.

Our subject is a 36-year-old man who presented to the emergency department with bilateral lower extremity amputation at the level of the distal third of the tibia after a car accident. Surgery was planned for below-knee amputation of the right lower extremity and replantation of the left foot. The arteries dissected from the iatrogenically amputated segment were used as grafts to repair vascular gaps during the replantation. The patient's follow-up had been problem free. We concluded that whenever possible, amputated parts unsuitable for replantation should be examined thoroughly and neurovascular structures that might be used as grafts should be preserved.

The feasibility of tissue expansion in reconstruction of congenital and aquired deformities of pediatric patients.

Skin expansion is one of the major developments in reconstructive surgery. The use of tissue expansion has been popularized among plastic surgeons and has become the treatment method of choice for many congenital and acquired defects in a wide variety of diseases in adults and then later in children. The authors analyze their clinical experience in the treatment of burn scars and complex defects by tissue expansion in pediatric patients. The study included thirty five expansion procedures performed in 25 patients. Smooth surface expanders with a remote valve were used in the scalp (22), face (2), neck (3), hand (2), thorax (2), breast (1), palate (2), abdomen (1). Self-inflating osmotic tissue expanders were used in four patients, one of them had cleft palate and the other two of them had congenital hand anomalies and the last one had frontal scar and alopecia in the frontal hairline. In 19 out of 25 cases (76%) tissue expansion was achieved without complications. At the same time, in 1 cases minor complications and in 5 cases major complications occurred. The number of expanders per patient was only one in 16 cases. More than one expander was used to remove parts of the same injury in 9 cases. Our study may help to draw attention again on different aspects in tissue expansion and critically focus on each step of the tissue expansion both using self-filling tissue expanders and smooth surface tissue expanders with a remote valve.