A simple concept for covering pressure sores: wound edge-based propeller perforator flap.

We present a new surgical modification to allow propeller perforator flaps to cover pressure sores at various locations. We used a propeller perforator flap concept based on the detection of newly formed perforator vessels located 1 cm from the wound margin and stimulated by the chronic inflammation process. Between January 2009 and January 2017, 33 wound edge-based propeller perforator flaps were used to cover pressure sores at various locations in 28 patients. In four cases more than one flap was used on the same patient. The patients comprised 18 males and 10 females with a mean age of 41·25 (range, 16-70) years. All patients underwent follow-up for 0-12 months. The mean follow-up duration was 5·03 months. Venous congestion was observed in three flaps that were rotated by 180° (9·1%). However, there was a significant difference between flaps rotated by 90° and 180° according to the complication rate (P = 0·034). Out of 33 flaps, 29 flaps healed uneventfully. Patients were able to sit and lie on their flaps three weeks after surgery. In our study, we were able to obtain satisfying final results using these novel flaps.

Reconstruction of hand injuries with multiple metacarpal defects using free fibular osteoseptocutaneous flap.

Hand injuries with multiple metacarpal involvements often include midpalmar muscle, extensor tendon, and skin defects. Reconstruction method is decided according to the type and amount of structures to be restored. Bone reconstruction and resurfacing of the skin is regarded as priority, and restoration of tendon function and joint mobility can be left for further procedures. An ideal flap for such defects should provide bone for multiple metacarpal defects and a large enough skin paddle. Such flaps are few, and one of the most suitable of them all is the free fibular osteoseptocutaneous flap (free FOSCF). In this report, our experience with the use of free FOSCF for reconstruction of the mutilating hand injury in five patients with extensive skin integument and metacarpal involvement has been presented. Total lengths of fibular flaps were averagely 11 cm in length and were divided into averagely 2.4 segments. Average dimensions of the skin paddles were 7.75 × 8.75 cm. Although the nature of the devastating traumas limited the ultimate functional recovery; wound closure, stability, and various degrees of mobility were restored in all patients. In our experience, reconstruction with free FOSCF proved to be an effective tool in mutilating hand injuries with metacarpal involvement.

Vascular pathological changes in rat lower extremity and timing of microsurgery after electrical trauma.

The purpose of this study was to form a standard electrical trauma model in rat, to investigate the pathological changes in vessels, and to determine the best day for performing microsurgery. In the preliminary study, 20 rats were divided into five groups. One was control, and the rats in the other four groups were exposed to 240 V electrical potential for 5, 10, 15, and 20 seconds, respectively. Femoral vessels from each group were biopsied for electron and light microscopy. In the study group, 36 rats were subjected to 240 V electrical trauma for 18 seconds. The rats in the study group were divided into three groups. On days 3, 7, and 21, the femoral artery of nine rats in each group were cut and anastomosed. The anastomoses were followed for thrombus formation. Visible, respectively increasing necroses were seen in all animals in the second, third, and fourth preliminary study groups. Light and electron microscopy revealed degeneration of vessel walls and loss of endothelium. Second and third microsurgery study groups had statistically significantly more thrombus. Although after electrical trauma major vessels seem normal, they have pathological changes, and microsurgery success rates are decreased shortly after electrical trauma.

Supraclavicular artery flap.

Supraclavicular artery-based flaps provide aesthetic and functional coverage for the head and neck region. Fourteen formalin-fixed cadavers were dissected bilaterally, and 28 supraclavicular arteries were evaluated. The origin of the supraclavicular artery was transverse cervical artery in 62.9% and suprascapular artery in 37.1% of the cases. The origin of the artery was at the level of the medial third of the clavicle in 3.7%; 3.7% of the cases were at the junction of medial and middle third of the clavicle, 33.3% at the level of middle third of the clavicle, 11.1% at the junction of middle and lateral thirds, 44.4% at the level of lateral third, and 3.7% at the level of acromioclavicular joint. The mean values of the results were as follows: The diameter of the artery was 1.0 mm at the origin. The distance of the origin of the artery from sternoclavicular joint and from the upper border of the clavicle was 76.4 and 22.2 mm, respectively. The average length of the artery was 70.8 mm. In all dissections, the artery was deep to the platysma muscle. Forty-one percent of supraclavicular arteries accompanied the middle supraclavicular nerve, whereas 59% of the arteries run with lateral supraclavicular nerve. The supraclavicular artery had a parallel course to the 2 horizontal imaginary lines passing from the coracoid process and acromion in 63% of the cases; 18.5% of the arteries were oblique, and 18.5% were vertical to the imaginary lines. The venae comitantes were double in all dissections.

Anatomic bases of superficial temporal artery and temporal branch of facial nerve.

The superficial temporal artery (STA)-based flaps have been used for different reconstructive purposes. These operations may cause facial nerve injury. The variations of the STA and its relation to temporal branch of the facial nerve (TBFN) were evaluated in this study. Thirteen cadavers with 26 STA and TBFN have been dissected. The bifurcation of STA was found to be 60% above the superior border of the zygomatic arc and 40% below this level. The mean lengths of frontal and temporal branches (FB and TB) of STA were 11.5 and 11.4 cm, respectively. The mean numbers of perforators of FB and TB to deep plane were 1.30 and 1.34, respectively. The mean diameter of STA at the superior border of zygomatic arc was 2.5 mm. The mean diameters of TB and FB at the level of bifurcation were 1.8 mm and 2.0 mm, respectively. The mean number of TBFN at the level of zygomatic arc was 3.70. The mean distance of the first and last branching of TBFN to tragus was found to be 24 mm. The mean number of TBFN at the level of the middle orbita was found to be 2.7. The mean distance of first and last branches of TBFN to the lateral orbital rim was 12 and 24 mm, respectively. The results found in this study may increase the accuracy of flaps based on STA and decrease the risk of facial nerve paralysis during these operations.

Anatomy of gracilis muscle flap.

Gracilis muscle flap is commonly used in reconstructive surgery. The gracilis muscles of 15 formalin-fixed adult cadavers (30 cases) were dissected with 4× loupe magnification. The most proximal pedicle of gracilis muscle was the deep branch of the medial circumflex femoral artery. It was located 60 mm from the pubic tubercle and had a diameter of 0.9 m on the average. The second pedicle was the medial circumflex femoral artery. It was the dominant pedicle in 13% of the cases. The mean diameter of the artery was 1.2 mm, and it entered the muscle 98 mm from the pubic tubercle. The third artery that nourished the muscle was deep femoral artery. It was the dominant pedicle in 87% of the cases. It had a mean diameter of 1.6 mm with a length of 54 mm. The most distant pedicles originated from the superficial femoral artery. They were present in all cases and were double in 77% of the cases. Mean diameter and length of the artery were 1.4 and 52 mm, respectively. They entered the muscle 266 mm from the pubic tubercle. These distal pedicles seem to be large enough to elevate the middle part of the muscle as a free flap.

Anatomy of vastus lateralis muscle flap.

A vastus lateralis muscle flap is used as a pedicled and free flap. In this study, the vastus lateralis muscles of 15 adult formalin-fixed cadavers (30 cases) were dissected. The dominant pedicle was found to be descending branch of the lateral circumflex femoral artery. The mean diameter of the artery was found to be 2.1 mm. This pedicle was located 119.4 mm distal to the pubic symphysis. The mean length of the major pedicle was found to be 56.8 mm when the dominant pedicle was chosen to nourish the flap. The dominant pedicle entered the muscle 155.8 and 213.7 mm from the greater trochanter and the anterior superior iliac spine, respectively. The muscle had proximal minor pedicles from the ascending and transverse branches of lateral circumflex femoral artery. These arteries had mean diameters of 1.8 and 2.0 mm, respectively. The distal minor branches were present in all of the dissections. The distal branch had a mean diameter of 1.8 mm. The origin of this distal branch was located 83.7 mm proximal to the intercondylar line. The motor nerve of the vastus lateralis was found to be originating from femoral nerve. The nerve entered the muscle 194.6 mm from the anterior superior iliac spine.

Comparison of free anterolateral thigh flaps and free muscle-musculocutaneous flaps in soft tissue reconstruction of lower extremity.

BACKGROUND: The objective of this study was to compare the free muscle-musculocutaneous flaps and free perforator skin flaps used for soft tissue reconstruction of the lower extremities. METHODS: Fifty-three patients whose skin and soft tissue of the lower extremities had been reconstructed were divided into two groups: a perforator flap group, reconstructed using anterolateral thigh (ALT) free flap (23 cases), and a muscle-musculocutaneous flap group, in whom latissimus dorsi and rectus abdominus muscle-musculocutaneous free flaps were used (30 cases). Postoperative complications, long-term results, and donor site morbidities were studied in the two groups. RESULTS: Complete flap survival was 78.3% with four total and one partial flap loss in the ALT group and 90.0% with one total and two partial failure in the muscle-musculocutaneous flap group. Muscle-musculocutaneous flaps were the flaps of choice in Gustillo grade IIIB-C injuries and for reconstruction of more proximal localizations. ALT was preferred in relatively younger patients and was typically used for coverage of the distally localized defects. Flap complication rate was significantly higher in the ALT group, but the overall complication rate was similar between the groups. CONCLUSION: ALT perforator flap is a precious option for lower extremity soft tissue reconstruction with minimal donor site morbidity. Nevertheless, the beginners should be attentive to an increased rate of flap complications with the ALT flap and free axial muscle-musculocutaneous flaps would still be the tissue of choice for coverage of leg defects for a surgeon before gaining enough experience with perforator flap dissection.

Total vaginal reconstruction with combined 'Split Labia Minora Flaps' and full-thickness skin grafts.

PURPOSE: Vaginal reconstruction with split-thickness skin grafts is the most common method for total vaginal reconstruction. Although it has disadvantages like contraction of the graft, foreshortening, donor site morbidity and long-lasting periods of vaginal standing; its easy surgical technique makes it popular. A new method using split labia minora (LM) flaps and full-thickness skin graft is discussed in this study. METHOD: A 19-year-old female was presented with amenorrhea. A total absence of vagina was present and the patient underwent a total vaginal reconstruction for possible sexual intercourse. RESULTS: We observed no contraction and no foreshortening with a patent vaginal cavity up to 11 cm and 4.5 cm width. The need for continuous standing period was as short as 4 weeks and for intermittent standing up to 4 months. Sexual intercourse was encouraged after 4 weeks. During sexual intercourse no external lubrication was reported to be needed. There was no need for further reconstructive intervention. CONCLUSION: Vaginal reconstruction in congenital vaginal agenesis with split LM flaps and full-thickness skin grafts is a simple and effective method, which shortens the standing period and decreases the contraction in neovagina. Total vaginal reconstruction with split LM flaps could also be possible; to achieve this goal, expansion of LM flaps could be a further alternative.

In vivo intraaneurysmal pressure measurements in experimental lateral wall aneurysms before and after onyx embolization.

BACKGROUND: The aim of this study is to measure and compare the in vivo intraaneurysmal pressures of experimental lateral wall aneurysms, before and after onyx embolization. The data of this experiment will carry an important role in forming the scientific basis for the clinical endovascular applications. MATERIALS AND METHODS: Five experimental lateral wall aneurysms were created by microsurgical techniques in 5 New Zealand rabbits' right common carotid arteries. Onyx embolization was applied to the aneurysms. Intraaneurysmal dome pressure and parent artery measurements before and after the procedure were recorded. RESULTS: The mean arterial pressure recording in parent artery was 69.2 +/- 2.588 mm Hg under anesthesia. Mean heart rate was 131 beats per minute. The values were in physiologic limits. Meanwhile, aneurysm intradomal pressure recording showed a mean value of 59.2 +/- 5.069 mm Hg. Although there was incomplete occlusion of the aneurysm, intradomal mean pressure was recorded to be 24.4 +/- 8.876 mm Hg. After complete occlusion by onyx, mean intradomal aneurysm pressure was found to be 1.8 +/- 0.836 mm Hg. DISCUSSION: This study is the first study reporting on intraaneurysmal pressure measurements before and after onyx embolization. The results in this experiment tend to show the adequate intraaneurysmal pressure control of onyx. This is important in the stabilization of the aneurysm to prevent rupture and rerupture. When compared with the findings of GDC coil, onyx embolization seems to be superior in intraaneurysmal pressure control. CONCLUSION: In this study, it has been shown that onyx embolization decreases the intradomal aneurysmal pressure effectively.

Follow-up form for patients undergoing orthognathic surgery.

Patients undergoing orthognathic surgery need quantitative follow-up of many parameters. Standardization and recording of data should be done with minimal paper work and time. The patient follow-up form presented enabled the authors' clinic to increase the quality of follow-up. The form consists of more than 20 variables that are routinely evaluated in all patients undergoing orthognathic surgery. It facilitates the cross-evaluation of many variables easily and more accurately. This type of accurate recording would also be beneficial in the event of medico-legal issues. The authors believe this form would be helpful to clinics that have a large number of patients undergoing orthognathic surgery.

Anatomic study of the vasculature of the submental artery flap.

The submental artery island flap is a versatile option in head and neck reconstruction. This flap may be used for the coverage of perioral, intraoral, and other facial defects, leaving a relatively acceptable donor-site scar. In this study, the submental region of 13 formalin-fixed cadavers was dissected bilaterally. Comprehensive anatomical information regarding the pedicle of the flap and its relationship with the important adjacent structures is provided. The mean values of the measurements of the facial and submental arteries were as follows: the facial artery was 2.7 mm in diameter at the origin, and it crossed the mandibular border 26.6 mm from the mandibular angle. The origin of the submental artery was 27.5 mm from the origin of the facial artery, 5.0 mm from the mandibular border, and 23.8 mm from the mandibular angle. The diameter of the submental artery was 1.7 mm at the origin. The artery was found mostly to course superficial to the submandibular gland. In one case, the artery passed through the gland. The total length of the submental artery was 58.9 mm. The artery anastomosed with the contralateral artery in 92 percent of the cadavers. The submental artery was deep to the anterior belly of the digastric muscle in 81 percent of the cases. This study presents detailed anatomical data about the location, dimension, and relationship of the facial artery, the submental artery, and the submental vein that may be useful during dissection of the submental artery island flap.

Prevention of peritendinous adhesions following flexor tendon injury with seprafilm.

Peritendinous adhesions are the most important complication of flexor tendon injury. In this study, Seprafilm was used for the prevention of peritendinous adhesions following flexor tendon repair. Seprafilm Bioresorbable Membrane (Genzyme Corporation, Cambridge, MA) contains sodium hyaluronate and carboxymethyl cellulose. Thirty New Zealand white male rabbits were divided equally into 3 groups. In all groups, the deep flexor tendon of the third finger of the left back foot was cut and repaired by Kessler-Tajima suture technique. In the first study group following tendon repair, Seprafilm was wrapped around the repaired tendon. In the second study group, sodium hyaluronate gel was injected to the operation field after tendon repair. In the control group, no external material was applied to the field. The study groups had better range of motion. Histopathologically, study groups had less adhesions compared with the control groups. As a result, it was concluded that in rabbit the peritendinous adhesions following flexor tendon repairs could be lowered with Seprafilm and hyaluronic acid.

Cadaveric study of the arterial anatomy of the upper lip.

Arterial distribution of the upper lip was investigated in this study. The location, course, length, and diameter of the superior labial artery and its alar and septal branches were determined on 14 preserved cadaver heads. Another cadaver head was used to show the arterial tree by the colored silicone injection technique. The superior labial artery was the main artery of the upper lip and always originated from the facial artery. The superior labial artery was 45.4 mm in length, with a range from 29 to 85 mm. The mean distance of the origin of the superior labial artery from the labial commissura was 12.1 mm. The superior labial artery was 1.3 mm in external diameter at its origin. The mean distance of origin of the superior labial artery from the lower border of the mandible was 46.4 mm. The alar division of the superior labial artery was mostly found as a single branch (82 percent). Its mean length was 14.8 mm and the mean diameter at the origin was 0.5 mm. The distance between the origins of the superior labial artery and the septal branch was 33.3 mm. The septal branch was single in most of the cases (90 percent). The mean length of the septal branch was 18.0 mm and the diameter at its origin was 0.9 mm. After all dissections, it was concluded that the arterial distribution of the upper lip was not constant. The superior labial artery can occur in different locations unilaterally and bilaterally, with the branches showing variability.

Arterial anatomy of the lower lip: a cadaveric study.

The aim of the study was to investigate the arterial anatomy of the lower lip. The location, course, length, and diameter of the inferior labial artery and the sublabial artery were revealed by bilateral meticulous anatomic dissections in 14 adult male preserved cadaver heads. Another cadaver head was used for silicone rubber injection to fill the regional arterial tree. The inferior labial artery was the main artery of the lower lip and in all cases branched off the facial artery. The mean length of the inferior labial artery was found to be 52.3 mm (range, 16 to 98 mm). The mean distance of the origin of the inferior labial artery from the labial commissura was 23.9 mm. The mean external diameter of the inferior labial artery at the origin was 1.2 mm. The sublabial artery was present in 10 (71 percent) of the cadavers. Mean measurements of this artery were 1 mm for diameter, 23.4 mm for length, and 27.6 mm for distance from the labial commissura. The sublabial artery may originate from the facial artery or the inferior labial artery. This study found that this region does not have a constant arterial distribution, the inferior labial artery and the sublabial artery (if it exists) can be in different locations unilaterally or bilaterally, and the diameter and the length may vary.

Giant ganglion cyst of the quadriceps femoris tendon.

We present the case of a ganglion cyst with 11 x 3 x 2 cm dimensions originating from the quadriceps femoris tendon. The patient presented with palpable mass and chronic pain in the anterolateral thigh region. The pain increased with walking. Ultrasonography and computed tomography revealed a cystic, well defined lesion in the vastus lateralis muscle. The patient was operated on and the cyst excised; it was seen to be a ganglion cyst. The patient is asymptomatic 6 months after surgery. This is a very rare localization for a giant synovial cyst, and preoperative diagnosis is a challenge for the surgeon.