Double Opposing U Suture For Septal Multiple Axis Deviations: A Multi-Vectoral Approach.

Septal cartilage deviations comprise the majority of deformities related to revision rhinoplasty operations. Therefore, the primary operation should be as eventless and durable as possible. Many techniques have been suggested, but most present with a monoplanar correction and fixation of the septum. This study aims to demonstrate a suture method that fixates and broadens the deviated septum. This method employs a single-stranded suture passing below the spinal periosteum, pulling the posterior and anterior portions of the septal base separately. It was utilized in 1578 patients, of which only 36 necessitated a revision of septoplasty in the past 11 years (2010-2021). With a revision rate of 2.29%, this method should be considered a preferable choice over many techniques described in the literature.

A Useful Tool for Various Problems in Nasal Tip: The Cephalic Transdomal Suture.

ABSTRACT: Surgical manipulation of the nasal tip is a critical point in functional and aesthetic rhinoplasty procedure. Cephalic strip excision from the lower lateral cartilages, elongation or shortening the caudal septum, structural grafting for supporting the medial and lateral crura are major structural moves in building a durable cartilaginous framework. However, it is suture techniques that make up the final touch in fine tuning of the shape, projection, definition, and angulation (rotation) of the nasal tip over this framework.Problems with fine-tuning of the nasal tip include inadequate or excessive definition, or projection resulting with bulbous or boxy appearance can be overcome reversibly with correctly placed sutures. One of the most decisive sutures in this context is transdomal sutures. Incorrect placement of which can result with too narrow or too wide nostril apices, as well as a cephalic malposition deformity of the lower lateral cartilages, botching an otherwise perfectly executed rhinoplasty procedure.In this article, cephalad placement of the transdomal sutures, and its relevance is disclosed in 223 consecutive cases of primary rhinoplasty.

Pitanguy Ligamentous Flap: A New Method to Prevent Supratip Deformity in Rhinoplasty.

BACKGROUND: A supratip deformity (SD) is an iatrogenic convexity that occurs in the cephalic region of the nasal tip. SD is still a major problem after rhinoplasty surgery. OBJECTIVES: With the method we have described a ligamentous flap was used to create a supratip transition, with adjustable sharpness, while the refinements of the tip rotation and definition were ensured. The aim of the study is to present the results of this technique, which, to the best of our knowledge, has been described here for the first time. METHODS: Our ligamentous flap technique was applied to 24 patients between August 2017 and March 2018. All of the patients were evaluated in terms of the formation of an SD, a hanging columella, tip projection, and the loss of rotation at the postoperative followups. The photos of patients were evaluated by another independent plastic surgeon and patients themselves at 3 months after the surgery. RESULTS: There were no early or late complications, such as an infection, excessive bleeding, or prolonged edema. Moreover, SDs, hanging columellas, tip projections, and rotational losses, which would require revisions, were not detected in any of the patients. Postoperative scores given by the patients and surgeons were significantly higher than the preoperative values (P < 0.05). Only 2 patients required minor revisions due to dorsal irregularities in the upper 1/3 of the nasal segment. CONCLUSION: The early results of this Pitanguy composite flap technique, which can be easily applied in every case with thin or thick skin in an open rhinoplasty, are promising. However, there is a need for an evaluation of the long-term results, as well as the advantages and disadvantages in a larger case series. LEVEL OF EVIDENCE: Level IV.

Simultaneous Autologus Mandible and Temporomandibular Joint Reconstruction.

Ablative surgery of mandible often necessitates combined reconstruction of the mandible and the temporomandibular joint. Fibula-free flaps with gap arthroplasty or osseochondral grafts are common procedures in the authors' practice. In search for a better reconstructive option free fibula flap is used together with a metatarsal bone flap for the vascular reconstruction of the mandibular body and the condyle at the same time. The 2 osseous-free flaps have been fused and used as a combined flow through double-free flap. The literature has been reviewed for other reconstructive options, but no alternatives providing autologous reconstruction of both the mandible and the condyle with vascular tissue have been found. This is a preliminary report of this new technique which the authors humbly think is very promising.

The evaluation of flap growth and long-term results of pediatric mandible reconstructions using free fibular flaps.

Currently, the free fibular flap is well accepted as the first choice for mandibular reconstruction. Achieving functional results in pediatric patients requires a different approach than that employed for mature patients. Because the pediatric craniofacial skeleton continues to grow, reconstruction is more challenging, and the long-term results can be different from those of adult patients. In this study, we sought to measure flap growth objectively in our series. Ten pediatric patients who underwent reconstruction with free fibular flaps were retrospectively reviewed. Flap growth was evaluated by comparing the intraoperative photographs with photographs of the control panoramic mandibular radiographs taken using photo-anthropometric techniques. The measurements were converted to proportionality indices (PI), and these indices were compared. Subsequent complications and functional results were also evaluated. The mean patient age was 11.8 years, and the mean follow up was 57.7 months. The mean preoperative PI value was 10.74 ± 2.47. The mean postoperative PI value was 12.52 ± 2.34. The mean difference between the preoperative and postoperative PI values was -1.78 ± 0.53. These photo-anthropometric data clearly illustrated the growth of the fibular flaps (P = 0.001). None of these patients exhibited nonunion of the fractures; however, one patient experienced a delayed union, one had chronic temporomandibular joint pain, and one had chronic temporomandibular joint luxation. In two patients, the inter-incisive measurements were below the third percentile, and two additional patients had grade 2 eating abilities, which can be regarded as poor. All of the patients had symmetric mandibular contours. Free fibular flaps continue to grow in pediatric patients. This flap is a "workhorse" flap in children because it adapts to the craniofacial skeleton via its ability to grow, and this ability results in subsequent good cosmetic and functional results.

The effect of melatonin on a dorsal skin flap model.

BACKGROUND: Melatonin (Mel) has a very potent antioxidant activity, depending mainly on its capacity to act as an electron donor. Recently, the antioxidant property of Mel has been much emphasized. In this study, the dorsal skin flap model was used to investigate the effect of Mel in flap viability in rats. MATERIAL AND METHODS: Totally 28 Wistar Albino rats were divided into four groups: control group (C) (n = 7), local treatment group (L) (n = 7), systemic low-dose melatonin treatment group (LT) (n = 7), and systemic high-dose melatonin treatment group (HT) (n = 7). The necrosis rate of the skin flaps was observed seven days after the operation by a blinded observer. Oxidative stress was assessed by determining malondialdehyde (MDA) level, and effects of melatonin on antioxidant enzymes such as superoxide dismutase (SOD) and catalase (CAT) were measured. Vascularity, epithelial thickness, and fibroblast proliferation of dorsal skin flaps were assessed histologically. RESULTS: Amount of MDA were found significantly lower (p < .05), and the flap viability, CAT, SOD, vascularity, fibroblast proliferation, and epithelial thickness were found significantly higher (p < .05) in groups HT than in groups C, L, and LT statistically. CONCLUSION: Our results showed that the usage on different doses of melatonin could play an important role in the process of flap viability and further studies will focus on these areas of interest.

Y-to-V setback for prominent lobule correction in otoplasty.

Prominent ears may be very distressing for the patient and they need to be corrected. The situation is especially important for school children or the teenagers as it may cause peer criticism and psychological issues. Various techniques have been suggested, and it is possible to obtain a successful result with one of these techniques chosen according to the patient's specific needs and the surgeon's preference. However, there are not many publications regarding the finer details of this operation such as the correction of the prominent lobule. There are few techniques available with limited success. In this study, we humbly present our Y-to-V setback technique for correction of the prominent lobule, as an individual operation or as an adjunct to a successful otoplasty. A total of 22 cases in which prominent lobule correction had to be performed during otoplasty were included in our study. Mean age of the patients was 21.3 years. Of the 22 patients, 14 were female and 8 were male. All cases underwent bilateral lobule transposition together with bilateral otoplasty. All cases have been followed up for at least 12 months. Mean follow-up was 20 months. The lobule incisions were inconspicuous, and they were well hidden in the postauricular sulcus. Hypertrophic scars or keloid were not seen in any cases. No relapse of lobule prominence was seen during the follow-up period. All patients were satisfied with their results. One of the reasons the ears may look unnatural or "operated" after an otoplasty is the disharmony of the lobule with the corrected parts. Even normal lobules may become relatively prominent after medialization of the helix. It is suggested that the use of a "v"-shaped advancement flap elevated from the posterior surface of the lobule may be a very useful technique to set the lobule back to the desired extent.

New alternative in treatment of callus.

The pathological transformation of the skin into a thick and hard callus due to repetitive trauma or friction is commonly known as corn. Although a variety of medical and operative treatment choices have been proposed, an ideal treatment method is yet to be defined. Effectiveness of tangential excision together with topical cantharidin has been evaluated. We used Canthacur-PS as an adjunct to excision in an outpatient setting. Canthacur-PS is a commercially available topical solution that includes 1% cantharidin, 30% salicylic acid and 5% podophyllin. The treatment has been applied to 72 patients. We found that 65 patients (90.3%) had corn on their feet and seven patients (9.7%) on their hands. Thick, hard and hyperkeratotic skin area was scraped with the help of a no. 15 blade. The solution was applied on and around the periphery (up to 1­2 mm) of the lesion with a cotton swab, and kept closed for 5 days with an antibiotic dressing. All the patients had been followed up for at least 1 year and evaluated by clinical examination and patient satisfaction query. One session of treatment succeeded in 57 (79.2%) corn patients. Two sessions in nine corn patients (12.5%), three sessions in five corn patients (6.9%) and four sessions in one patient (1.4%) were needed. Only one recurrence (1.4%) was seen. No scar formation or other side-effects were seen. Our findings show that this treatment method is a simple, minimally invasive and reliable treatment for calluses.

Management of nasal deformity in osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a rare hereditary disorder of collagen synthesis that results in weak bones that are easily fractured resulting in deformities. Osteogenesis imperfecta refers to a wide array of genetic disorders with variable phenotypic presentation. In general, type I is the mildest form of disease; types IV, III, and II, respectively, increase in severity. There is lack of knowledge about the feasibility of nasal surgery in patients with bony disorders in the literature. Although rhinoplasty is one of the most frequent procedures all over the world, there are only very few case reports about OI patients undergoing rhinoplasty. The authors could find 2 old case reports, published in 1965 and 1977. The only recent publication that could be found was published in 2000, but it was about a follow-up case that had been operated 15 years ago. A 24-year-old woman with OI who has been operated on because of severe airway obstruction and cosmetic reasons is presented. Open rhinoplasty was performed, keeping in mind that bones and cartilages are more fragile, and they heal late in OI. Therefore, greenstick fractures were preferred instead of median osteotomies, and cartilages were fixed to each other at multiple points with nonabsorbable sutures. There were no complications in the postoperative period, and the patient was very satisfied with her breathing and appearance. Current literature is reviewed in accordance with our experience with this unique case. In conclusion, good cosmetic and functional rhinoplasty results may be obtained in OI cases with careful case selection, limited mobilization of the nasal bones, and careful fixation of the nasal cartilages with nonabsorbable sutures.

Marjolin ulcers arising on extremities.

Marjolin ulcer, epidermoid carcinoma arising on nonhealing scar tissue, is well known for its aggressiveness compared with other forms of squamous cell carcinoma. It is thought to be even more aggressive when it arises on an extremity. Therefore, Marjolin ulcer located on an extremity is unique in its aggressiveness and calls for immediate attention and extensive surgery. We have treated 81 patients with extremity lesions between 1982 and 2003, 62 of which have been followed up for at least 5 years. The cases that were lost to follow-up and our more recent cases have not been included in this study. Medical records of these 62 patients were reviewed retrospectively. All the lesions were carcinomas arising on old burn scars. The mean age was 48.0 years. The average interval between burn and carcinoma was 35.9 years. Male to female ratio was approximately 1:2. About 72.6% of the patients were treated with wide local excision only and 21.0% of the patients had wide excision together with regional lymph node dissection. Only 6.4% of the cases have been treated with amputation combined with regional lymph node dissection. Postoperative regional lymph metastasis was seen in 40.3% of the patients and 41.9% of the patients have developed lung metastasis during the follow-up. Presence of metastasis, high histologic grade, and tumor size were found to have a direct effect on survival rates. The mean survival was 4.55 for the whole study group. The 5-year survival rate was 42.9% in upper extremity and 58.3% in lower extremity groups. Estimated mean time of survival for the disease has been calculated to be 7.76 years using statistical analysis. We suggest that tumor size is an important prognostic factor in addition to histologic grade. Treatment algorithm is reviewed, and the importance of adequate surgery is emphasized.

Osteogenic capacities of tibial and cranial periosteum: a biochemical and histologic study.

The periosteum has an important role in bone regeneration. The purpose of this study was to evaluate and compare the osteogenic capacities of tibial and cranial periosteum. To achieve this, 44 New Zealand male rabbits were divided into two groups, each consisting of 22 rabbits. In group 1, periosteal flaps were prepared on the tibia of the posterior cruris of each side. In group 2, bilateral periosteal flaps were prepared on the cranial region. New bone formation was estimated quantitatively by measuring the alkaline phosphatase and osteocalcin levels, because they are the indicators of osteoblastic activity. At weeks 1, 2, 4, and 8, biopsies were taken from five animals of each group for biochemical analyses, and at weeks 2 and 8, biopsies were taken for histologic evaluation. Higher alkaline phosphatase and osteocalcin levels were evaluated in group 1, and more bone formation was observed in group 1. The results showed that osteogenic capacity is higher in tibial periosteum than cranial periosteum.

Free-tissue transfers for reconstruction of oromandibular area in children.

INTRODUCTION: Currently, free-tissue transfers are commonly used for various reconstructive purposes in adults. However, there is a lack of large series of free flap reconstruction in children, especially for reconstruction of oromandibular defects. Our study aims to share our experience in free-flap reconstruction of some challenging pediatric cases. MATERIALS AND METHODS: Pediatric free-flap interventions (<18-year-old) that were performed between 2000 and 2006 in our clinic were retrospectively evaluated. Eighteen free-tissue transfers were performed in 17 pediatric cases. Epidemiologic data, etiology, defects, preferred free flaps, and results have been compared and analyzed. RESULTS: A total of 17 patients (18 free flaps) were analyzed. Mean age was 10.4 years. The etiology was tumor in 11 cases, traffic accident in 5 cases, and gunshot in 1 case. Double-flap transfer was performed to one patient with a devastating shotgun wound and single flap transfers to others. A total of 8 osseous flaps, 7 osteocutaneous flaps, and 3 septocutaneous flaps were transferred. Total superficial flap necrosis was encountered in one flap (5.8%) while partial superficial necrosis was seen on two flaps (11.7%). Sixteen of the 17 cases reconstructed, including the three cases with complications, resulted in good functional and cosmetic outcome. One case was lost in the sixth postoperative month due to septisemia during chemotherapy. All the surviving 16 cases acquired bony fusion, mastication, and speech in addition to good cosmetic results. CONCLUSION: Pediatric free-tissue transfers are increasing due to the development of better equipment, finer surgical technique, and a better understanding of the unique characteristics of pediatric cases. In our opinion, high success rates with good cosmetic and functional results can be obtained if the specific requirements of the pediatric procedures are met.

Reconstruction of the distal third of the nose with composite ear-helix free flap.

Full-thickness defects of the nose result in severe esthetic and functional problems. Regardless of the etiology of such defects, the complexity of the reconstruction process of full-thickness defects of this region is not correlated with the size of the defect. Local flaps are frequently used for reconstruction but often yielding facial scarring and bulky alae. Composite helical grafts are used for relatively small defects but defects of more than 2.0 cm in diameter require vascularized tissue transfer. Composite free flap from the root of the auricular helix has been used to reconstruct an anatomically diverse set of defects of the distal third of the nose, with satisfactory success in our series of 6 patients.

[Surgical coverage technics of pressure sores and their outcomes]. / Basi yarasi olan hastalara uyguladigimiz cerrahi tedavi yöntemleri ve sonuçlari

BACKGROUND: We reviewed the outcome of 66 patients with 100 pressure sores between 1984 and 2002. METHODS: In the current study, 100 pressure sores in 66 patients (45 male, 21 female; mean age 39.4; range 13 to 80 years) who underwent surgical repair of pressure sores reconstructed using myocutaneous or fasciocutaneous flaps, skin grafts, excision and closure. RESULTS: The risk factors for pressure sores included acute trauma-induced spinal cord injury in 40 (61%) patients with paraplegia and in 5 (7%) patients with quadriplegia; congenital spina bifida and multiple sclerosis in 7 (11%) patients and prolonged immobilization in 14 (21 patients) patients. We achieved an overall pressure sore recurrence rate of 22% and overall patient recurrence of 24% in a-3-year follow-up. The recurrence rates according to anatomic sites; 23% (10 of 43) for the ischial pressure sore, sacral 21% (8 of 37), and trochanteric 20% (4 of 20). Fasciocutaneous and myocutaneous flap reconstructions were the most durable, as they were associated with 17% (6 of 34) and 12% recurrence rates (5 of 39). CONCLUSION: To reduce the recurrence rates the authors advocate the use of myocutaneous and fasciocutaneous flaps instead of skin grafts or direct closure for the coverage of pressure sores.

Van der Woude syndrome in twins.

This article discusses monozygotic twin patients with Van der Woude syndrome, the most common form of syndromic cleft lip and palate, who have concordant manifestations. The syndrome has an autosomal dominant hereditary pattern with variable expressivity and a high degree of penetrance with clinical features, including lower lip sinuses with a cleft lip, cleft palate, or both. Some mutations have been found to cause this disorder. Genetic counseling and informing patients about inheritance is crucial. The appearance, etiology, genetic aspects, differential diagnosis, and treatment modalities are discussed. To the authors' knowledge, this is the third report of monozygotic concordant twins with this syndrome in the literature.

Free fibula flap mandible reconstruction in benign mandibular lesions.

The mandible may be affected by a variety of pathological conditions such as ameloblastomas, odontogenic keratocysts, central giant cell granulomas, fibro-osseous lesions, and osteomas. They generally are benign, and conservative treatment can be enough in most of the cases. However, they can be clinically aggressive, and especially ameloblastomas, odontogenic keratocysts, and fibro-osseous lesions are prone to recur. The method of treatment remains a matter of controversy in these cases. The aim of this analysis was to study 100 patients who had been treated for benign mandibular lesions, and to emphasize the importance of free fibula flap in the treatment of such lesions.

Alopecia treatment with scalp expansion: some surgical fine points and a simple modification to improve the results.

In the current study, authors present their clinical experience with the esthetic reconstruction of alopecia by means of a tissue expansion technique in 74 consecutive patients who were treated between May 1986 and June 2002 in the Department of Plastic and Reconstructive Surgery. The principles of the conventional technique are mentioned briefly, but the authors essentially tried to explain a number of surgical fine points together with some simple modifications so as to get the maximum profit from the expanded tissue and to decrease the complication rate. In the first 39 patients of this study, who were treated with a conventional tissue expansion technique, the major complication rate was found to be 15.4%. In the last 35 patients, this rate was found to be decreased to 5.7%. The improvement in the major complication rate is attributed to the authors' surgical modifications compared with the conventional technique. The article provides a supplement to the existing literature, underscoring the importance of some surgical fine points and outlining a systematic way of planning expander placement and tissue expansion.

Comparing the osteogenic capacities of bone substitutes: hydroxyapatite, high-density porous polyethylene, and bone collagen: a biochemical and histological analysis.

Several inorganic materials have been shown previously to hold some osteogenic capacity. The purpose of this study is to compare the bone-forming abilities of hydroxyapatite ceramic, high-density porous polyethylene, and bone collagen within the periosteal island flap of rabbit tibia using histological and biochemical analysis. With this goal, four discrete experimental groups were formed, each comprising 22 New Zealand male rabbits. A sac was created on each rabbit tibial periosteum flap in each of the groups, and each of the previously mentioned materials was placed within this sac separately. One of these groups was thought as a control group without any material being placed inside the periosteal sac. Biopsies were taken at weeks 1, 2, 4, and 8 for biochemical analysis and at weeks 2 and 8 for histological evaluation. Neo-osteogenesis was evaluated quantitatively by determination of alkaline phosphatase and osteocalcin levels biochemically as well as by the percentage of new bone formation inside the periosteal sac histologically. Results show statistically that the osteogenic effect of high-density porous polyethylene is greater than that of the other materials used in this study (P < 0.05).

A rare location of benign osteoblastoma: review of the literature and report of a case.

Benign osteoblastoma is a rare primary bone tumor that constitutes approximately 1% of all primary bone tumors. Its occurrence in the craniomaxillofacial region as also rare and represents only 15% of all osteoblastomas. The tumor shows a predilection for the male gender and constitutes less than 1% of all tumors of the maxillofacial region. In the maxillofacial region, the mandible is affected more frequently than the maxilla, and the coronoid process of the mandible is the area most rarely affected by osteoblastoma. Before this report, 53 cases have been reported in the literature. In this report, a rare location of osteoblastoma, namely, the coronoid process of the mandible, is described.

Benign osteoma with Gardner syndrome: review of the literature and report of a case.

Gardner syndrome, a variant of familial adenomatous polyposis, is an autosomal dominant disease characterized by gastrointestinal polyps that develop in the colon as well as in the stomach and upper intestine (duodenum), multiple osteomas, and skin and soft tissue tumors. Cutaneous findings include epidermoid cysts, desmoid tumors, and other benign tumors. Polyps have a 100% risk of undergoing malignant transformation; consequently, early identification and therapy of the disease are critical. Osteoma is a benign neoplasm of bone tissue that is characterized by slow continuous growth and is the most common accompanying bone lesion seen in Gardner syndrome. The authors report a case of Gardner syndrome that was operated on because of the mandibular osteoma.