The surgical treatment of plagiocephaly.

AIM: Anterior plagiocephaly usually occurs with premature synostosis of the ipsilateral half of the coronal suture. The forehead is flattened on the affected side, with a backward and upward displacement of the affected orbit. The bulging of the calvaria may occur in the contralateral parietal area. MATERIAL AND METHODS: This article presents the surgical techniques used over 7 years to treat plagiocephalic children. Eleven patients with unilateral coronal synostosis treated during 2003-2010 were analyzed retrospectively. The study included reviews of pre and postoperative computed tomography scans, operative techniques, clinical outcomes and complications. Unilateral orbital advancement with "tongue in groove" was performed in 5, and bilateral orbital advancement in 6 cases. Pre and postoperative anthropometric measurements were used to document the amount of advancement of the elevated and recessed orbita, and the amount of withdrawal of the contralateral side. RESULTS: The mean age of the patients at time of surgery was 11 months. The preoperative values of the orbital height and retrusion were 0.68 cm and 1.87 cm, respectively. They were recorded as -0.1cm and 0,63 cm, postoperatively. Mean follow-up was 36 months, neither neurological sequelae nor other significant complications were encountered. CONCLUSION: The surgical corrections have resulted in significant improvements in skull shape and high patient/parent satisfaction.

Idiopathic scrotal calcinosis: surgical treatment and histopathologic evaluation of etiology.

Patients with idiopathic scrotal calcinosis present with multiple, asymptomatic calcified nodules on the scrotum that appear in childhood or early adulthood. The scrotal skin can be extensively affected, and scrotal reconstruction with complicated procedures usually seems to be needed after excision. However, primary closure is usually achievable. Two cases are presented with histopathologic findings of scrotal calcinosis. The possible etiologies are discussed, and the therapeutic alternatives are reviewed.

Neural fibrolipoma of a digital nerve of the index finger without macrodactyly.

We present a case of neural fibrolipoma arising from the digital nerve in the index finger of the right hand. A 31-year-old man was referred with a soft tissue mass in the ulnar aspect of the index finger of his right hand, which had gradually enlarged during the past seven years. Histological examination of an excisional biopsy specimen identified a neural fibrolipoma, which is a differential diagnosis of a lipomatous lesion of the digits.

Jack-like eversion by splitting the orbicularis oris muscle for reconstruction of the philtral column in secondary cleft lip.

The philtrum is an important aesthetic unit that contributes hugely to the characteristics of the human face. From March 2002 to May 2006 inclusive, a total of 16 patients with unilateral cleft lip nose were operated on to form a philtral column and obtain muscular continuity. Six of the patients were female and 12 were male, age range 5 to 30 years old. We used Millard's method, so rotation and advancement flaps were planned. A full thickness incision was made down to the orbicularis oris muscle and mucosa after the scar on the philtral column had been excised. The medial and lateral muscle flaps were exposed and split into two leaves at the coronal plane. The deepest part of the muscle flaps were sutured together to create a jack-like eversion. Skin and mucosa were then closed. The follow-up period ranged from 8 to 18 months (mean 11 months). Two visual analogue scales were used to assess the outcomes. Thirteen of 16 patients were satisfied with their good result. Three had moderate results. The advantages of the technique are: ease of use; the creation of an anatomically-natural philtrum while preserving the continuity and function of the muscle; sufficient augmentation of the philtral column by the jack-like eversion; and no donor-site morbidity.

Freestyle perforator-based V-Y advancement flap for reconstruction of soft tissue defects at various anatomic regions.

BACKGROUND: Perforator flap surgery has gained great popularity in the last decade because surgeons can prepare freestyle flaps in anywhere on the body if they find a perforator supplied to the flap. One of the basic principles of reconstructive surgery is that superior results can be obtained for color and texture match if immediately adjacent soft tissue is used to repair a defect. V-Y advancement flaps are used successfully based on this principle, but the degree of mobility of a V-Y advancement flap is dependent on the laxity of the underlying subcutaneous tissue. This is an important disadvantage of traditional V-Y advancement flap and limits its use. METHODS: We used V-Y advancement flaps as perforator-based to overcome mobility restriction problem. The authors used 26 perforator-based V-Y advancement flaps in 24 consecutive patients for coverage of defects located at sacral (4), thigh (6), abdominal wall (3), inguinal (3), back (4), leg (2), and trochanter (2) regions. There were 14 female and 10 male patients with a mean age of 48.3 years (range, 22-70 years). RESULTS: The patients were followed up for a mean period of 14.2 months (range, 9-21 months). The size of the defects ranged from 3 x 5 cm to 15 x 20 cm. All flaps survived completely (92.4%) except 2 in which one of them had undergone total necrosis and the other had marginal necrosis. Fifteen flaps (57.6%) were elevated based on 2 perforators, 7 flaps (26.9%) were used with only one perforator, and the remaining 4 (15.5%) had 3 perforators. CONCLUSIONS: Perforator-based V-Y advancement flaps are safe and very effective for coverage of defects in which closure is impossible with a standard V-Y advancement flap. Dissection of the perforator or perforators offers remarkable excursion to the V-Y flap with minimal donor site morbidity. These axial pattern flaps can be used successfully with good esthetic and functional results at various regions of the body if there is any detectable perforator.

Reconstruction of large orbital exenteration defects after resection of periorbital tumors of advanced stage.

Orbital exenteration is a devastating procedure because of the social impact and psychological stress put upon the patient. Besides cancer ablative surgery, reconstruction after removal of the tumor constitutes a major problem and the final aesthetic result is quite important. Both obliteration of the orbital cavity and continuation of the epithelial lining are required. Free rectus abdominis muscle and musculocutaneous flaps are versatile flaps which both enable filling the cavity and reconstituting the skin defect with a cutaneous portion or with a skin graft. Both free rectus abdominis muscle and musculocutaneous flaps were used for reconstruction of orbital exenteration defects in 19 patients. All suffered partial maxillectomy as well. The flaps provided satisfactory aesthetic results in all patients.

Free flap choice for soft tissue reconstruction of the severely damaged upper extremity.

Reconstruction of complex wounds of the hand associated with severe bone, tendon, nerve and soft-tissue injuries has been a major problem in hand surgery. Early definitive soft-tissue coverage of this kind of extensive wound with well-vascularized tissue is one of the most important stages of reconstruction for salvage of the extremity and restoration of function. Although multiple free flap donor sites have been described for complex upper extremity wounds, the authors think that anterolateral thigh (ALT) and lateral arm (LA) flaps are good choices for soft-tissue reconstruction in the upper extremity because of their reconstructive characteristics. These flaps can be used as flow-through and also sensate flaps. There is no need for position change intraoperatively and two teams may work simultaneously. Donor sites can be hidden and there is no required sacrifice of major artery or muscle.

Use of fascia component of the anterolateral thigh flap for different reconstructive purposes.

The anterolateral thigh flap is commonly used for reconstruction of soft-tissue defects located at various sites of the body. This versatile flap offers many advantages to the reconstructive microsurgeons for the treatment of difficult defects. From 2000 to 2005, 70 anterolateral thigh flaps were transferred to reconstruct soft-tissue defects. We retrospectively reviewed these patients and found that the fascia lata component of the flap was used for different purposes in 19 patients. The fascia lata component of the flap was used for suspension of the flap in lip reconstruction in 12 patients, for reconstruction of dural defect in the scalp in 2 patients, for reconstruction of tendon defects in the forearm in 3 patients, and for reconstruction of fascia defect in the abdominal wall in the remaining 2. Complete loss of the flap was seen in an anterolateral thigh flap (5.2%) that was used for lower lip reconstruction. One flap necrosed partially (5.2%), and it was treated with surgical debridement and transposition of latissimus dorsi musculocutaneous flap. The objective of this study is to focus on the reliability of the fascial component of the anterolateral thigh flap. Although many authors have described other advantages of the anterolateral thigh flap extensively, this peculiarity has not been stressed adequately. Anterolateral thigh flap offers a thick and vascular fascial component with large amounts that can be used for different reconstructive purposes, and it should be taken into consideration as an important advantage of the flap, together with other well-known advantages.

The true triplication of the thumb: a case of unclassified thumb polydactyly.

A child with true triplication of the thumb is reported. Each thumb has a well-developed metacarpal, and one of them is biphalangeal; the remaining 2 are triphalangeal. Satisfactory result was obtained from a functional and esthetic point of view. Our surgical approach to this interesting anomaly and the necessity of a new group under the Wassel classification for the categorization of different forms of thumb triplications is discussed.

Effects of clopidogrel and high dose aspirin on survival of skin flaps in rats.

Clopidogrel is a new antiplatelet agent with a different mechanism of action from aspirin. It is thienopyridine derivative that is chemically related to ticlopidine, which irreversibly inhibits platelet aggregation by selectively binding to adenylate-cyclase-coupled adenosine diphosphate receptors on the platelet's surface. Aspirin is an antiplatelet agent that acetylates cyclo-oxygenase and decreases the products of arachidonic acid metabolism, including thromboxane and prostacyclin. Necrosis of a flap is still an important complication in reconstructive surgery. To investigate the effects of clopidogrel or high dose aspirin on the survival of skin flaps, 30 rats were divided into three groups of 10 animals each: a control group, a clopidogrel group, and a high-dose aspirin group. No pharmacological agents were used in the control group. Of the two treated groups, the first was given clopidogrel 50 mg/kg/day and the second aspirin 200 mg/kg/day for three days before the operation. After seven days the viable areas of each flap were evaluated and the mean (SD) percentage in the control group was 47 (6), in the clopidogrel group 63 (4), and in the aspirin group 65 (5). Although the mean area of flaps that survived in the aspirin group was slightly higher than in the clopidogrel group, the difference was not significant (p = 0.54).

Ice application to minimize pain in the split-thickness skin graft donor site.

Reconstruction of tissue defects with skin grafts is one of the most used processes in soft tissue defects. While any part of the body can be used as a donor site of split-thickness skin grafts, the posterolateral thigh is the most used one. Pain in the graft donor site may be the primary concern of patients in the postoperative period. Various kinds of donor site dressings and procedures have been described for this purpose. The main goal of this practice is the fast recovery of the donor site. Nevertheless, avoiding infection, decreasing the pain in the donor site, and minimizing the cost should be considered. To minimize pain in the graft donor site, ice pack application, used for its local anesthetic effect, was utilized for patients postoperatively in our clinic. Thirty-six patients were included in this study between June 2001 and May 2002. Patients were divided into two groups, with 18 patients in-group I, to whom ice was applied, and 18 patients in group II, which was specified as the control group. The patients were evaluated according to the pain in the graft donor site. The visual analog scale (VAS) was used to evaluate the pain of the patients. The data were statistically evaluated with the Mann-Whitney U test procedure. In addition to this, infections, recovery periods, and cost benefit effects were also determined. The mean pain scores in the graft donor site were found to be quite low in patients in the group with ice application (p < 0.05). No significant difference was determined between the two groups when their pain scales were compared on the fourth and the fifth days (p > 0.05). Ice can be safely used in patients for whom donor site pain is the primary concern, with advantages such as ease of application, low cost (almost free), and a significant decrease in pain in the donor site.