The New Anatomical Classification System for Orbital Exenteration Defect.

BACKGROUND: The unique anatomy of the orbita and the different behavior of each malignant tumor cause us to perform the various types of orbital exenteration that yields to varying defect each of which has own specific demands in terms of the reconstruction. Current classification of orbital exenteration defects seems not to be adequate to provide detailed description. This study reviews 50 exenteration defects to offer a more effective anatomical classification system. METHODS: Over a 15 years period, 50 orbital exenteration defects in 47 patients were reconstructed. Defects were categorized according to the resected orbital wall, dura, and ethmoid resection. If the maxillectomy was performed, A or B was added to define the type of maxillectomy as partial (intact palate) or total maxillectomy, respectively. According to these criteria, 4 types of defect patterns were determined including Type 0 (n = 5) with intact orbital wall, Type I (n = 9) with sino-orbital fistula, Type II (n = 4) with crania-orbital fistula with intact dura, Type III (n = 6) with crania-orbital fistula associated with dura defect, and Type IV (n = 8) with cranio-nasal-orbital fistula. There were 12 partial (A) and 6 total maxillectomy (B) defects along with the orbital exenteration. RESULTS: There was no major complication except one. The minor wound-healing problems occurred in 7 patients. Nine patients (19%) used prosthesis. Twenty-two (46.8%) patients chose a patch to cover the area. The remaining 16 patients were not able to use any type of prosthesis because of the reconstruction methods. CONCLUSION: The authors believe that the authors' anatomical classification system provides more precise description of the defect which eventually enhances the success rate of both reconstruction and resection.

Origin, Reality, and Clinical Importance of the Arcade of Struthers: An Anatomic Study.

The literature contains confusing and opposing views about the naming, prevalence, anatomic structure, and clinical significance of the arcade of Struthers. The conflicting rates of arcade (between 0% and 100%) prevalence found in the literature may be due to the varying definition of the arcade among the authors, as well as the dissection method. The present study aims to examine the structure to determine whether or not the arcade of Struthers exists through an anatomic dissection study of a fresh human cadaver and seeks to compare its findings with those in the literature. Twenty arms from fresh frozen cadavers were dissected. An arcade of Struthers was not found in any specimen. Study concluded that its existence is unproven, and the arcade of Struthers does not exist.

Pachydermoperiostosis: aesthetic treatment of prematurely aging face with facelift and botulinum toxin a.

Pachydermoperiostosis is a rare syndrome that hinders patients' quality of life thru its aesthetics manifestations and functional obstacles. Many techniques for addressing and correcting aesthetic defects associated with pachydermoperiostosis have been introduced, including facelift surgery. This case presentation includes treatment of facial pachydermoperiostosis and restoration of facial aesthetics via treatment with facelift, skin muscle excision, and botulinum toxin A.

Postradiation sarcoma from a free flap.

INTRODUCTION: Postradiation sarcomas constitute approximately 0.5% to 5.5% of all sarcomas. They develop locally approximately 3 to 20 years after the administration of radiotherapy (RT). They are generally high-grade tumors. Osteosarcomas, fibrosarcomas, malignant fibrous histiocytoma, angiosarcomas, and leiomyosarcomas are the most frequently observed. It is rare for these tumors to originate from free flaps, and this patient report is one of the first in the literature. PATIENT: A 59-year-old man was operated on because of ethmoid sinus cancer in 2004, and the reconstruction was performed with a rectus abdominis free muscle flap. He received postoperative RT and subsequently presented to our clinic with a medially protruding mass on his upper jaw. A biopsy was performed. Its pathologic diagnosis was reported as malignant mesenchymal tumor. Computed tomography and magnetic resonance imaging were performed, demonstrating that the mass originated from the free muscle flap (m. rectus abdominis) at the front wall of the sphenoid sinus. A total excision of the free muscle flap and near-total maxillectomy were performed. The pathologic finding was reported as leiomyosarcoma with bone invasion. DISCUSSION: With the advancement of medical and pharmaceutical technologies, our patient's life expectancy is increasing. In long-living patients who have received RT, tumors can develop 20 years after the RT. The close follow-up of patients receiving RT is of utmost importance because treatment survival is linked to early diagnosis and resection with negative surgical margins. We must not forget that, even if years have passed since receiving RT, these patients may present with such tumors.

Subacute and delayed period microsurgical management of traumatic extremity injuries in pediatric population.

The purpose of the present report is to evaluate the outcome of subacute and delayed period microsurgical reconstructions of traumatic extremity defects of the pediatric patients. Eighteen free tissue transfers had been performed in 18 patients. Patients ranged in age from 5 to 17 years of age and had a median age of 12.05 years. The time between trauma and free flap transfer varied between 8 and 86 days (mean, 30.8 days). Hospital stay ranged from 8 to 90 days, with a mean stay of 38.7 days. Postoperative complications were seen in 8 of 18 patients (44.4%). Re-exploration for venous thrombosis was necessary in two patients, and total flap loss occurred in one case. The average follow-up time was 34 months. One could conclude from our report and the reference literature that the frequently quoted dogma of a definitive defect closure within 7 days may have lost much of its justification. The final results obtained after delayed definitive soft tissue reconstruction compare favorably with results previously reported in the literature from patient groups whose wounds could be closed in the early period within 7 days.

The epidemiology of foot wounds in patients with diabetes: a description of 600 consecutive patients in Turkey.

Epidemiological studies describing demographic, clinical, and surgical characteristics of diabetic foot wounds are lacking in Turkey. To further describe the epidemiology of diabetic foot wounds in Turkey, we developed an evaluation form and performed a retrospective cohort study that entailed 600 diabetic patients who were admitted to the hospital for treatment of their foot wound(s). The mean age of the cohort was 62.3 ± 10.3 (range 23-92) years, and their mean duration of diabetes was 17.4 ± 7.4 years. Males accounted for 68.17% of the cohort, and 96.83% of the cohort had type 2 diabetes. Prevalences for lower extremity arterial pulses and peripheral neuropathy, as well as the location, depth, microbiology, and surgical treatment of the pedal wounds are also presented. In conclusion, diabetic foot wounds are common in Turkey, and the morbidity associated with these lesions is generally substantial. Although our investigation aimed primarily at describing risk factors associated with diabetic foot wounds, we believe that the findings of this investigation can be used in the development of prospective cohort studies and randomized controlled trials that focus on foot wounds in diabetic patients in Turkey, and may be useful to investigators in other parts of the world.

A reliable surgical approach for the two-staged amputation in unsalvageable limb and life threatening acute progressive diabetic foot infections: tibiotalar disarticulation with vertical crural incisions and secondary transtibial amputation.

BACKGROUND: If all efforts to treat acute progressive diabetic foot infection remain insufficient, the decision of major amputation should be undertaken. For this purpose, guillotine amputation is usually performed first. However, guillotine amputation below the knee level may cause the corresponding infection to spread to preserved anatomical spaces. METHOD: First stage of our procedure consists of tibiotalar disarticulation and vertical incisions performed throughout the lower leg to remove the septic foot and drain the compartments. During the interval period, appropriate antibiotherapy and wound care are applied. After the interval period, definitive transtibial amputation is performed in the second stage. RESULTS: Fifty-nine percent of the 62 transtibial amputations were healed completely. Failure developed in 3 cases which required opening of the amputation stump. In one patient, revision amputation at a higher transtibial level was done. Infection and necrosis reached to the knee joint in the other two patients and transfemoral amputation became the only treatment option for these 2 cases. CONCLUSION: Tibiotalar disarticulation with vertical lower leg incisions as a first stage of two-stage transtibial amputation is a safe and reliable method. It reduces the risk of unnecessary tissue sacrifice and failure rate of the secondary transtibial amputation.

A new composite flap model in the rat: combined cremaster muscle and pubic bone flap.

BACKGROUND: We introduce a new model of combined cremaster muscle and pubic bone flap based on a single pedicle consisting of the osseous branch of pubic bone and external spermatic vessels of cremaster muscle in continuity with the pudic-epigastric artery (PEA). METHOD: Thirty male Sprague-Dawley rats weighing 200 to 250 g were used in this study. In 10 rats PEA, a branch of the iliac artery was dissected throughout its entire course for the anatomic study. We observed that after giving the external spermatic artery to the cremaster muscle and external pudendal branch to the penis, the PEA continued its course over the ipsilateral pubic bone that was thought to nourish the pubic bone. In 20 rats, the flap was raised on the PEA for the flap study. Five flaps were used for microangiographic study. Remaining 15 rats were used for scintigraphic assessment and dye injection and histologic study. RESULTS: Microangiographic evaluation revealed the vascularity of all components of the flap as provided by the pedicle. Bone scintigraphy performed at 7th postoperative day demonstrated radionuclide uptake by the bone segment of the flap, indicating the bone viability. In addition, the dye injection study revealed ink staining within blood vessels of the cortex and the marrow of the pubic bone. CONCLUSION: To the best of our knowledge, this is the first report describing the combined cremaster muscle and pubic bone flap model in the rat. It seems to have an important advantage over the other composite osteomuscular flap models in terms of the cremaster muscle being suitable for the intravital microscopy. Besides being harvested from a small animal species, it is reliable, versatile, and relatively easy to dissect with quite long isolated vascular pedicle, which allows a greater range of flap displacement. It can be used for different applicability including microcirculatory, pharmacologic, physiological, biochemical, and immunologic studies, as well as for the transplantation studies.

Reverse-flow retroauricular island flap in facial reconstruction.

BACKGROUND: Reconstruction of facial skin defects requires good-quality skin cover to satisfy aesthetic expectations of patient, especially when the skin defect is on the uncovered area of the face. Limitations in the available local tissue and donor-site morbidity restrict the options. OBJECTIVE: In an effort to solve these problems, we have begun to use a subcutaneous pedicled retroauricular reverse-flow flap. METHODS: Between January 1997 and December 2005, reverse-flow subcutaneous pedicled retroauricular island flap was used to cover facial defects in 12 patients who underwent surgical excision of skin tumor. The patients ranged in age from 44 to 81 years with a mean age of 58 years. RESULTS: Only one case experienced a superficial necrosis in the distal one-quarter part of the flap. The functional and aesthetic results were satisfactory for both patients and surgeons, and no tumor recurrence was observed during the 12 to 28 months (mean, 18.8 months) follow-up period. CONCLUSIONS: This flap can be used reliably for the reconstruction of facial skin defects of small and medium size. The preference of frontal branch pedicled flap enables more distal facial area defects to be covered, such as dorsal nasal, nasolabial, and upper lip, than flaps based on parietal branch.

Skin Necrosis in a Patient with Factor V Leiden Mutation following Nipple Sparing Mastectomy.

Nipple-sparing mastectomy (NSM) and immediate breast reconstruction have replaced radical surgical interventions for the treatment of selected patients with breast cancer undergoing prophylactic mastectomy. NSM is technically a difficult procedure. After dissection, the remaining breast skin and nipple-areola complex (NAC) must be thin enough to be free of tumor tissue and thick enough to preserve tissue perfusion. Factor V Leiden mutation is the most common cause of hereditary thrombophilia; thrombosis almost always develops in the venous system. The literature includes only a few case series of arterial thrombosis. The present study aimed to describe for the first time a patient with Factor V Leiden mutation that developed nipple-areola complex and skin necrosis, and multiple embolisms in the upper extremity arteries following NSM.

Ganglion cyst associated with triangular fibrocartilage complex tear that caused ulnar nerve compression.

Ganglions are the most frequently seen soft-tissue tumors in the hand. Nerve compression due to ganglion cysts at the wrist is rare. We report 2 ganglion cysts arising from triangular fibrocartilage complex, one of which caused ulnar nerve compression proximal to the Guyon's canal, leading to ulnar neuropathy. Ganglion cysts seem unimportant, and many surgeons refrain from performing a general hand examination.

Mandibular metastases of papillary thyroid carcinoma treated by hemimandibulectomy and costochondral rib graft.

Papillary thyroid carcinoma (PTC) is the most common and well-differentiated cancer of the thyroid. Unlike most cancers, spread to local lymph node does not worsen the survival rate of PTC, and complete resection of the metastases seems to be important and may have favorable effects on the prognosis. A 33-year-old woman was referred to our clinic with a mass involving the right angulus mandible. Incisional biopsy of the mass diagnosed follicular variant of papillary thyroid carcinoma. Right hemimandibulectomy was performed and reconstructed with costochondral rib graft. The patient survived for 5 years after the hemimandibulectomy. Metastases to the oral cavity indicate a grave prognosis, but PTC has relatively indolent biological behavior; long-term survival is usually possible even in patients with metastatic disease.

The Overlapped Triple Circle Pulse Technique with Nd:YAG Laser for Refractory Hand Warts.

BACKGROUND AND OBJECTIVE: Inadvertent superficial treatment of hand warts causes recurrence, whereas aggressive treatment can lead to tissue defects resulting in hand dysfunction. This study aimed to determine the effectiveness of a novel laser treatment modality for recalcitrant hand warts. MATERIALS AND METHODS: The study included 51 patients who were treated for 146 recalcitrant hand warts using 1064 nm long-pulsed Nd:YAG laser between 2011 and 2014. The laser treatment method is novel because each treated wart was aligned at the intersection point of the circles of 3 laser pulses per session. RESULTS: Among the 146 hand warts, 88.35% were successfully treated with one session and 100% of those that required a second treatment session were treated successfully, based on the 12 month follow-up examination. CONCLUSIONS: Long-pulsed Nd:YAG laser treatment was observed to be a safe, rapid, and effective method for treating recalcitrant hand warts.

A Novel and Alternative Treatment Method for Diabetic Heel Ulceration Exposing the Calcaneus Which Is Not Suitable for Flap Surgery: Vacuum Assisted Sandwich Dermal Matrix.

BACKGROUND: Currently, free flaps and pedicled flaps are the first treatment choices for large heel ulcer reconstruction. However, flap reconstruction of heel ulcerations cannot be performed in all diabetics especially with concurrent severe peripheral vascular disease because of higher flap failure rate. In recent years, the use of acellular dermal matrix (ADM) has emerged as an alternative treatment option for extremity ulcers. METHODS: We present 13 diabetic patients with a large heel ulceration exposing the calcaneus, who were not eligible for flap surgery due to the presence of only one patent artery of trifurcation. These cases were treated with the vacuum assisted sandwich dermal matrix (VASDEM) method. RESULTS: None of the patients required amputation. Skin grafting was successful in ten patients. Although partial losses were observed in three patients, they were healed spontaneously without surgical interventions. During the follow-up period none of the patients developed ulceration on the treatment area. All patients maintained their preoperative ambulatory ability. CONCLUSION: VASDEM is a novel method offering opportunity for treatment before proceeding to amputation in diabetic heel ulceration exposing the calcaneus which is not suitable for flap surgery. It also has the potential to close wounds of all sizes independent of the vessel status and wound size in selected diabetic patients.

Laser lipolysis without suction: reality or myth?

BACKGROUND AND OBJECTIVE: Liposuction is one of the most frequently performed aesthetic surgical procedures. Laser- and ultrasound-based systems have become especially popular in recent years, including laser lipolysis, which has a number of advantages over classic liposuction. Some researchers contend that the aspiration step is not necessary. Herein, we report a case that highlights the negative consequences when the basic surgical rule of not leaving any necrotic tissue is not followed. MATERIALS AND METHODS: We report the case of a 50-year-old man who presented with a 15 cm mass in the right lower quadrant, located immediately subcutaneously, passing the midline infraumbilically, tender to touch, and with beginnings of abscess formation, who underwent laser lipolysis. The subcutaneous necrotic fat was removed with a skin island en bloc. No postoperative complications occurred and the patient was problem free 6 months post-surgery. RESULTS: In the surgical literature, most studies on fat necrosis have focused on fat necrosis in the breast. Fat necrosis is usually a gradual process that is noticed by the patient or physician as a mass. Radiologically, it can imitate cancer, especially in breast tissue. Complications from fat necrosis are primarily linked to the amount of necrosis. Any amount of necrosis above the body's resorption capacity will lead the body into attempting self-limitation, with consequences to both the physical and psychological health of the patient. CONCLUSIONS: We believe that claiming that no aspiration is required after laser lipolysis, without the necessary studies, has no scientific basis.

The effect of epidural anesthesia on muscle flap tolerance to venous ischemia.

BACKGROUND: Venous ischemia is a major cause of failure after free tissue transfers and replantations. The combination of general and epidural anesthesia leads to vasodilatation and improves tissue perfusion. Postoperative pain relief and sympathetic blockage are additional benefits of epidural anesthesia. The purpose of this study was to determine whether epidural anesthesia has benefits on microcirculation and neutrophil functions in muscle flaps subjected to venous ischemia. METHOD: Thirty Sprague-Dawley rats were divided into three groups: group I, general anesthesia; group II, spinal anesthesia; and group III, epidural anesthesia. Cremaster flaps were prepared, postcapillary venules were selected under intravital videomicroscopy, and flaps were subjected to venous ischemia. Images were recorded from preselected postcapillary venules before venous ischemia (baseline) and following reperfusion. Neutrophil rolling and adhesion, functional capillary density, and diameters of postcapillary venules were evaluated. RESULTS: The increase in rolling neutrophils in group III was significantly lower than in groups I and II at 60 and 120 minutes. Change of adherent neutrophils in group III was significantly lower than in groups I and II at 15, 60 and 120 minutes. There was significantly more reduction in inner diameter of postcapillary venules in groups I and II compared with group III. Functional capillary density in groups I and II was significantly lower than in group III. CONCLUSION: Epidural anesthesia regulated neutrophil functions, salvaged functional capillaries, and prevented vasoconstriction of postcapillary venules in cremaster muscle flaps subjected to venous ischemia. Spinal and general anesthesia, however, were found to be ineffective in improving microcirculation of muscle flaps subjected to venous ischemia.

Combined cremaster muscle and inner thigh skin composite flap: a novel experimental flap model in the rat.

Unlike the composite musculocutaneous flap models, the combined composite muscle-skin flap model allows evaluating muscle and skin viability independently, because it has an independent blood supply to the muscle and skin component. However, to our knowledge, only two combined muscle-skin flaps have been reported to date. During our cremaster dissection in our laboratory, we perceived a new vessel as a terminal continuation of the pudic-epigastric artery (PEA) on which the cremaster muscle flap is raised. Therefore, we designed this study to determine whether the scrotal and inner thigh skin can be harvested with the cremaster muscle as a combined cremaster muscle-skin composite flap. Thirty male Sprague-Dawley rats were used in this experiment. In five rats, ink study selective to the PEA marked a skin territory. In 15 rats, cremaster muscle and 4 x 3 cm ipsilateral scrotal and medial thigh skin flap was raised on the PEA. Fluorescein study after 4 hours showed fluorescein stain in the skin island. On postoperative day 7, both muscle and skin components of the flaps were viable. Microangiographic study after the flap elevation revealed the vascularity of all components of the flap and clearly identified the branch to the skin island. To the best of our knowledge, this is the first report describing the combined flap model including the cremaster muscle. Our flap seems to have an important advantage over the other combined muscle-skin flap models in terms of the cremaster muscle being suitable for the intravital microscopy. Additionally, the two components of the flap have separate nutrient vessels with adequate length, which gives the flap flexibility in the placement of the skin component in a location distant from the muscle component. The flap may be also be raised as a skin flap without the cremaster muscle. It can be used for different applications, including microcirculatory, pharmacological, physiological, biochemical, and immunological studies as well as for transplantation studies.

Conversion of the monocortical iliac bone graft to the three-dimensional prism bone graft.

INTRODUCTION: The iliac crest is the most common bone graft donor site. However, harvesting of tri or bi-cortical iliac bone graft is associated with some potentially serious complications and cosmetic deformity. We would like to present a case in which we used a new technique converting the mono-cortical iliac graft to the three-dimensional prism bone graft in order to reconstruct an acquired first metatarsal defect and to avoid the potentially serious complication of the iliac crest bone harvest. CASE REPORT: A six-year-old boy was referred to our institution due to the posttraumatic deformity of his left foot. He had a short big toe and dorsoflexion contracture of first metatarso-phalengeal joint due to the first metatarsus defect and previous skin graft. To reconstruct the bony defect, 4 x 3 cm monocortical bone graft was harvested from the anterior aspect of the ilium by using the peel-off technique. Then, the mono-cortical graft was converted to the prism with the appropriate osteotomies. This custom shaped tri-cortical prism bone graft was placed into the first metatarsal defect. Lateral arm fascia-cutaneous free flap was used for soft tissue reconstruction. The patient was able to walk without support and wear regular shoes and started playing freely with his friends at four months after the reconstruction. CONCLUSION: This is a single case report and demonstrates that a successful result can be obtained with this technique. Although the prism bone graft technique seems to offer a solution to a potential rather than a real problem, it offers a thick and three-dimensional cortico-cancellous bone graft without violating the iliac crest. Thus, the risk of serious complications resulting from the tricortical iliac crest graft or bicortical full thickness graft harvesting can be eliminated. Moreover, epiphysis of the immature iliac crest can be preserved in a growing child.