A simplified acute kidney injury predictor following endovascular aortic repair: ACEF score.

OBJECTIVES: Treatment of abdominal aortic aneurysms (AAA) with endovascular aortic repair (EVAR) has become quite common in recent years. This method, which has many advantages compared to the open surgical procedure, also has some complications. One of these complications is acute kidney injury (AKI). ACEF (age, creatinine, and ejection fraction) score, which is gaining popularity, can be an easy-to-use and cost-effective method in detecting this condition that causes increased morbidity and mortality. We aimed to evaluate whether this ACEF score may predict a development of AKI in patients who underwent EVAR. METHODS: A total of 133 consecutive patients with AAA who underwent EVAR were analyzed. The primary endpoint of the study was the development of AKI. The best cut-off value for the ACEF score to predict the development of AKI was calculated and according to this value, the patients were divided into two groups as those with high ACEF scores and those with low ACEF scores. ACEF score was calculated by the formula of age/EF + 1 (if baseline creatinine > 2 mg/dL). RESULTS: After the exclusion criteria, a total of 118 patients were included in the study, and 20 (16.9%) of them developed AKI after EVAR. In the ROC curve analysis, a cut-off value of 1.34 was found for the ACEF score, and scores above this value were found to be independent predictors of AKI development after EVAR. In addition to the ACEF score, the contrast media volume was also found to be an independent predictor of the development of AKI. CONCLUSION: In conclusion, ACEF is a simple and effective scoring system in patients undergoing EVAR. To the best our knowledge, our study is the first study which applies ACEF score to predict AKI in EVAR patients.

C-reactive protein to albumin ratio provides important long-term prognostic information in patients undergoing endovascular abdominal aortic repair.

BACKGROUND: The prognostic value of C-reactive protein/albumin ratio (CAR) is of import in cardiovascular diseases. Our aim was to evaluate the impact of the CAR in patients with asymptomatic abdominal aortic aneurysm (AAA) undergoing endovascular aneurysm repair (EVAR). MATERIAL AND METHOD: We retrospectively evaluated 127 consecutive patients who underwent technically successful elective EVAR procedure between December 2014 and September 2020. The optimal CAR cut-off value was determined by using receiver operating characteristic (ROC) curve analysis. Based on the cut-off value, we investigated the association of CAR with long-term all-cause mortality. RESULTS: 32 (25.1%) of the patients experienced all-cause mortality during a mean 32.7 ± 21.7 months' follow-up. In the group with mortality, CAR was significantly higher than in the survivor group (4.63 (2.60-11.88) versus 1.63 (0.72-3.24), p < 0.001). Kaplan-Meier curves showed a higher incidence of all-cause mortality in patients with high CAR compared to patients with low CAR (log-rank test, p < 0.001). Multivariable Cox regression analysis revealed that glucose ≥ 110 mg/dL (HR: 2.740; 95% CI: 1.354-5.542; p = 0.005), creatinine ≥ 0.99 mg/dL (HR: 2.957, 95% CI: 1.282-6.819, p = 0.011) and CAR > 2.05 (HR: 8.190, 95% CI: 1.899-35.320, p = 0.005) were the independent predictors of mortality. CONCLUSION: CAR was associated with a significant increase in postoperative long-term mortality in patients who underwent EVAR. Preoperatively calculated CAR can be used as an important prognostic factor.

Malnutrition provides important long-term prognostic information in patients undergoing endovascular abdominal aortic aneurysm repair.

OBJECTIVES: Malnutrition has been shown to be associated with survival in a variety of diseases. Our aim is to evaluate the prognostic value of objective nutritional indexes indicating malnutrition, in patients underwent endovascular aortic replacement. METHODS: We retrospectively evaluated 149 consecutive patients who underwent technically successful endovascular aortic replacement operation between October 2010 and August 2019. Objective nutritional indexes, prognostic nutritional index, geriatric nutritional risk index and controlling nutritional status, scores were calculated using the preoperative data. Optimal cut-off values were obtained by receiver operating characteristic analysis. According to the cut-off values, we investigated the relationship between indexes and the long-term all-cause mortality. RESULTS: During mean 48.0 ± 30.3 months follow-up duration, in 47 of patients (31.5%), all-cause mortality were documented. In mortality group, prognostic nutritional index (42.8 ± 7.1 vs 51.3 ± 5.2, p < 0.001) and geriatric nutritional risk index (100.7 ± 10.1 vs 107.6 ± 9.2, p < 0.001) were significantly lower, controlling nutritional status score (2.0 (1.0-4.0) vs 1.0 (0.0-2.0), p < 0.001) was higher when compared to survivor group. Kaplan-Meier curves presented higher mortality incidence in malnutrition patients evaluated with objective nutritional indexes (Log-rang test, for all three indexes p < 0.001). Besides Cox-proportional hazard analysis showed all three nutritional indexes may be a predictive marker for all-cause mortality, prognostic nutritional index introduced more valuable data than other two indexes. CONCLUSIONS: Malnutrition is associated with significant increase in postoperative long-term mortality in endovascular aortic replacement patients. Preoperatively calculated objective nutritional indexes especially prognostic nutritional index can be used as an important prognostic tool.

Novel markers of ventricular repolarization are associated with mortality in patients undergoing surgical aortic valve replacement for severe aortic stenosis.

INTRODUCTION: Aortic stenosis (AS) is the most common degenerative valvular heart disease that can affect left ventricular functions. Tp-e interval and Tp-e/QT ratio is a novel repolarization marker which is associated with adverse cardiovascular events in several cardiovascular diseases. In our study, our aim is to investigate the prognostic effect of Tp-e interval, Tp-e/QT and Tp-e/QTc ratios on mortality in patients who underwent successful surgical aortic valve replacement (AVR). METHODS: A total of three hundred seventy-five patients undergoing successful surgical AVR were included in this study. Then, patients were divided into two groups according to mortality as group 1 without mortality (342 patients) and group 2 with mortality (33 patients). Tp-e interval, Tp-e/QT, and Tp-e/QTc ratios were calculated for both groups. RESULTS: Tp-e interval (71 (63.7-77); 86 (84-88), p < .001), Tp-e/QT ratio (0.19 (0.17-0.20); 0.23 (0.22-0.23), p < .001) and Tp-e/QTc ratio (0.17 ± 0.02; 0.21 ± 0.01, p < .001) were higher in group 2 compared to group 1. In multivariate logistic regression analyses Tp-e interval (odds ratio [OR]: 1.315, 95% confidence interval [CI]: 1.203-1.437, p < .001), Tp-e/QT ratio (OR: 7.334, 95% CI: 3.274-1.643, p < .001) and Tp-e/QTc ratio (OR: 2.567, 95% CI: 4.106-1.605, p < .001) were found to be independent predictors of mortality. Additionally, a Kaplan-Meier survival analysis also revealed that long term survival was found to be significantly decreased in patients with higher Tp-e/QT ratio (Log-Rank p < .001) and Tp-e/QTc ratio (Log-Rank p < .001). CONCLUSION: Tp-e interval, Tp-e dispersion, Tp-e/QT, and Tp-e/QTc ratios are associated with worse prognosis after surgical AVR in patients with severe AS. All of them are also independent predictors of mortality.

Tip-Oriented Closed Rhinoplasty Built on Septocolumellar Suture and a New Caudal Septal Graft Technique.

BACKGROUND: A beautiful and appealing nose receives the greatest contribution from the nasal tip subunit, which should be regarded as the primary center of attention during a rhinoplasty procedure. In achieving the desired shape and position of the nasal tip during closed rhinoplasty, the septocolumellar suture functions as the major determinant together with the caudal portion of the septal cartilage, which has a significant influence on the versatility of the septocolumellar suture. The purpose of this study was to present the analysis of the indications, the technical steps, and the advantages of caudal septal graft and septocolumellar suture utilization in closed rhinoplasty. METHODS: The septocolumellar suture with or without the caudal septal graft combination procedure has been performed in 2286 patients via a closed rhinoplasty approach. Intraoperatively, the septal cartilage at hand was thoroughly evaluated and one of the 5 types of caudal septal grafts was used when necessary. After the establishment of a strong and straight septal cartilage with sufficient height and length, 4 different septocolumellar sutures in a specific order were used to modify the relationship between the lower lateral cartilages and the nasal septum. RESULTS: Of the 2286 cases, 1837 (80.3%) were primary and 449 (19.7%) secondary rhinoplasties, which have been followed up for 9 to 48 months. The caudal septal graft was combined to the septocolumellar suture in 621 (27.1%) patients. Of the caudal septal grafts, 69.7% were used for primary rhinoplasty cases, and 30.3% for secondary rhinoplasties. At the 18th month postoperatively, tip projection was found to be satisfactory for 98% of the patients. CONCLUSIONS: The septocolumellar suture combined with caudal septal graft in closed rhinoplasty substantially facilitates the achievement of a cosmetically and functionally pleasing end result, bringing the solution for a wide array of problems such as short nose, supratip deformity, nasolabial angle change, or columellar bowing. Nevertheless, the technique has a steep learning curve; therefore, a meticulous preoperative evaluation should be exerted, a precise surgical planning should be prosecuted, and an excessive reduction of the nasal tip or exaggerated columellar retraction should be avoided.

A New Perspective for Spreader Graft Use in Severely Deviated Septum: Is Septal Continuity an Obligation for a Stable and Straight Nasal Septum?

Severe septal deviation is a challenging deformity usually treated using aggressive surgical methods, and extracorporeal septoplasty (ECS) is a commonly used method for this issue. However, this method has severe risks and complications such as the recurrent deformity or nasal saddling. In this article, we present an alternative solution to ECS procedure for the correction of severe septal deviation. Sixteen patients with severe c- or s-shaped septal deviation with a mean age of 26.5 years were included in the study. The entire deviated part of the septal cartilage was resected as a vertical block creating a full-thickness defect between the most cranial and caudal parts of the septal cartilage. After that, two spreader grafts were placed bilaterally facilitating the septal integrity and leaving the full-thickness septal defect unchanged. The surgical results were evaluated using the preoperative and postoperative facial photographs and patient satisfaction was determined using nine relevant questions of DAS-59 scale. The only complication observed in the follow-up period of 19 months was hanging columella deformity which was corrected at the postoperative first year. The mean length of the resected septal segment was 12.4 mm. The mean length of the resultant septal cartilage defect after the vertical resection was 5.9 mm. The mean length of the placed spreader grafts was 25.6 mm. The comparison of the preoperative and postoperative photographs showed significant improvement of the nasal contour and considerable correction of the septal deviation. The statistical evaluation of the answers given to the questions of the DAS-59 scale clearly demonstrates that a significant degree of patient satisfaction was achieved. Severe septal deviation may be successfully corrected by full-thickness resection of the deviated part and reconstruction with bilateral spreader grafts with a low risk of postoperative complications.

Comparison of bone prefabrication with vascularized periosteal flaps, hydroxyapatite, and bioactive glass in rats.

BACKGROUND: Periosteal flaps possess osteoprogenitor cells and an osteoinductive potential that can be further augmented by combination with a biodegradable scaffold; therefore, various osteoconductive and osteostimulative biomaterials are frequently combined with periosteal flaps in studies of bone prefabrication. An experimental study was designed to determine and compare the contribution of bioactive glass and hydroxyapatite to osteoneogenesis in rats when combined with a periosteal flap. MATERIALS AND METHODS: In 60 Sprague Dawley rats, saphenous artery periosto-fasciocutaneous island flaps were transposed to abdomen. In group 1, the flap was left alone, in group 2, an empty artificial pocket made of Gore-Tex (W. L. Gore & Associates, Inc.; Flagstaff, AZ) was sutured onto the periosteal layer, and in groups 3 and 4, the pocket was filled with bioactive glass and hydroxyapatite, respectively. Following sampling for histological analysis, a 4-point scoring system was used to grade inflammatory cell infiltration, osteogenesis, angiogenesis, and cell migration into the bioactive material. RESULTS: The combination of the periosteal flap with any of the bioactive materials resulted in significantly higher percentages of animals exhibiting osteogenesis (80% in hydroxyapatite group and 93.3% in the bioactive glass group; p = 0.0000528) and angiogenesis. Comparison of the bioactive material groups revealed that a significantly higher proportion of animals in the bioactive glass group exhibited moderate or severe inflammation (80 vs. 20%; p = 0.002814). CONCLUSION: Periosteal flaps prefabricated with hydroxyapatite or bioactive glass in rats exhibit osteogenic capacities that are not dependent on direct bone contact or proximity to vascular bony tissue. The innate capacity of the periosteal flap when utilized alone for osteoneogenesis was found to be rather insufficient.

The impact of vessel clamps on endothelial integrity and function of saphenous vein grafts.

BACKGROUND: Saphenous vein graft (SVG) failure can be associated with endothelial damage during coronary artery bypass grafting (CABG). Endothelial damage may develop after application of occlusive vessel clamps on SVGs. This study was designed to investigate the effect of plastic and metal clamps on the endothelial integrity and function of SVGs. METHODS: Saphenous vein samples were obtained from 10 consecutive patients, who underwent an elective CABG using SVG. Plastic (group 1) and metal (group 2) clamps were sequentially applied on the vein. Each set of clamps (1 plastic and 1 metal) was removed and sampled at 5, 15, and 30 min, respectively. A short SVG segment was removed as control. The samples were fixed for histopathologic study using hematoxylin-eosin staining and immunostaining for endothelial nitric oxide synthase (eNOS) expression. In each group, endothelial, elastic tissue, muscular layer, and adventitial changes were investigated under light microscope and compared using a histologic scoring system. The intensity of eNOS expression was assessed using histochemical scoring system. RESULTS: In both groups, histopathologic examinations showed progressive endothelial damage in the zones of clamp application, compared with the control group (P<0.001). Histopathologic changes were more favorable with the metal clamps, compared with the plastic clamps, at 5 and 15 min. No significant increase in endothelial damage occurred after 15 min. The eNOS immunoreactivity of SVGs significantly decreased in the damaged areas of the endothelium (P<0.05). In metal clamps, the intensity of eNOS immunostaining was significantly high at 5 min, compared with plastic clamps (P<0.05). However, the intensity of eNOS expression in metal clamps was significantly lower than plastic clamps at 15 min (P<0.05). No significant difference was observed between the groups at 30 min. CONCLUSIONS: The endothelial cells can be better preserved with short-term application of SVGs with metal clamps rather than plastic clamps. These findings suggest that temporary use of metal clamps can be preferred without major effects on vascular integrity and function.

Surgical management of a congenital panda nevus with preexpanded triple forehead flaps and temporal island flap.

Congenital panda nevus or the divided nevus of the eyelids is a rare form of melanocytic nevus involving both upper and lower eyelids with the risk of future malignant transformation along with the patients' complaints about the cosmetic appearance. Delicate anatomic features of the eyelids and the limited skin redundancy of the periorbital region make the surgical removal and reconstruction difficult, even in mild cases with partial involvement of the eyelids. A case of congenital panda nevus involving upper and lower eyelids, the eyebrow, and part of the malar eminence and the nasal dorsum is presented. A multistaged surgical management of the lesion with staged excision and reconstruction with preexpanded forehead flaps, temporal island flap, and skin grafts is discussed.

A new experimental flap design: the saphenous artery periosto-fasciocutaneous flap of the rat.

Vascularized periosteal graft is a frequently applied flap model for bone prefabrication studies due to its inhabitance of osteoprogenitor cells and osteoinductive potential. Various bones such as rib and fibula are reported as a potential source for the harvest of the periosteal flap in experimental studies on higher species such as dogs and pigs, which necessitates a rather complicated and expensive experimental setting. Therefore a reliable and inexpensive small animal model on vascularized periosteal flaps is necessary for future research. A new saphenous artery based periosto-fasciocutaneous flap model in rats is described here, which is easily dissected and monitorized. In this experimental study, 15 male Sprague Dawley rats were operated and killed following a 3-month-long follow-up period . The histological analysis revealed heterotopic osteoneogenesis in 12 of 15 flaps (80%), whereas 14 flaps (93.3%) exhibited signs of angioneogenesis originating from the periostofasciocutaneous flap. The presented flap model promises to be an appropriate alternative for new studies where bone prefabrication methods are evaluated.

Rhythm disorders after isolated mitral valve surgery: Consideration of the variations of the sinoatrial nodal artery in choice of atriotomy.

Background: This study aims to investigate the effect of atriotomy approaches applied in mitral valve surgery and variations of the sinoatrial nodal artery on postoperative arrhythmias and the need for a temporary or permanent pacemaker. Methods: Data of 241 patients (108 males, 133 females, mean age: 53.7±12.3 years; range, 18 to 82 years) who underwent isolated mitral valve surgery with a median sternotomy between January 2009 and December 2019 were retrospectively analyzed. The patients were divided into three groups according to the surgical approach for mitral valve exploration as left atriotomy (n=47), transseptal (n=131), and superior transseptal (n=63). By scanning the hospital records, the origin of the sinoatrial nodal artery was determined in the coronary angiography images obtained before surgery. Postoperative rhythm changes were analyzed based on electrocardiography and telemetry recordings. Results: Temporary pacing was required in 31 (49.2%) patients in the superior transseptal group, 40 (30.5%) patients in the transseptal group, and 12 (25.5%) patients in the left atriotomy group, indicating a statistically significantly higher rate in the superior transseptal group (p=0.013). Permanent pacemaker implantation was required in only one patient (superior transseptal), indicating no significant difference among the groups. The first-degree atrioventricular block was seen in 28 (44.4%) patients in the superior transseptal group, 42 (32.1%) patients in the transseptal group, and 13 (27.7%) patients in the left atriotomy group (p=0.130). The PR interval in the postoperative period was longer in the superior transseptal group than in the left atriotomy group in patients with the sinoatrial nodal artery originating from the right coronary artery (p=0.049). No significant difference was observed among the surgical approaches regarding the PR interval in patients with the sinoatrial nodal artery originating from the left circumflex coronary artery after surgery. Conclusion: We believe that the choice of atriotomy in isolated mitral valve surgery and sinoatrial nodal artery variations do not affect permanent arrhythmia alone. Still, the superior transseptal approach causes the electrical conduction to slow down temporarily more than the left atriotomy and transseptal method.

Comparison of Postoperative Outcomes of Sutureless versus Stented Bioprosthetic Aortic Valve Replacement.

OBJECTIVE: Sutureless aortic valve replacement (Su-AVR) offers an alternative to supra-annular stented biological aortic prostheses. This single-center study aimed to compare early outcomes after aortic valve replacement with sutureless and conventional stented bioprostheses. METHODS: In this retrospective study, we analyzed 52 patients who underwent aortic valve replacement with sutureless and stented bioprostheses between January 2013 and October 2017. Sorin Perceval S sutureless valves were implanted in group 1 and Sorin Mitroflow stented bioprosthetic valves were used in group 2. Postoperative outcomes, including demographics, cardiopulmonary bypass (CPB) times, cross-clamp times, morbidity and mortality, as well as echocardiography in the first month, were compared. RESULTS: Mortality occurred in 1 (3.6%) patient in group 1, and in 2 (8.3%) patients in group 2 (P=0.186). Group 1 had significantly shorter CPB (61.6±26.1 min vs. 106.3±32.7 min, P=0.001) and crossclamp (30.9±13.6 min vs. 73.3±17.3 min, P=0.001) times. The length of stay in the intensive care unit (1.9±1.3 days vs. 2.4±4.9 days, P=0.598) and hospital stay (7.6±2.7 days vs. 7.3±2.6 days, P=0.66) were similar. Postoperatively, there was no statistically significant difference between the two groups in echocardiography results, and morbidities. The mean aortic valve gradient was 13.5±5.8 mmHg in group 1 and 14.5±8.0 mmHg in group 2 (P=0.634). Paravalvular regurgitation was diagnosed in 3 (10.7%) patients in group 1 and in 1 (4.2%) patient in group 2 (P=0.220). CONCLUSIONS: Su-AVR resulted in shorter cross-clamp and CPB times. However, early mortality, postoperative morbidity, and echocardiography results were similar between groups.

Sternocleidomastoid region restoration with lateral hemisoleus muscle incorporatied in free fibular flap for reconstruction of radical neck dissection and hemimandibulectomy.

In the treatment of head and neck carcinoma, radical cervical lymphadenectomy leaves the affected side of the neck devoid of the sternocleidomastoid muscle, thus more vulnerable to the unwanted side effects of the adjuvant radiotherapy. It also causes asymmetry and cosmetically unpleasant appearance of the cervical region. In the reported case with widely ulcerated squamous-cell carcinoma over mandible, hemimandibulectomy and radical neck dissection was performed. Following the mandibular reconstruction, the lateral hemisoleus muscle of the harvested osteomyocutaneous fibula flap was utilized to restore the ipsilateral sternocleidomastoid region. This new application promises to be a useful method, which can aid in the restoration of the aesthetic contour of the neck and provide protection against unwanted effects of the adjuvant radiotherapy on the ipsilateral carotid artery.

A complication of nasotracheal intubation after mandibular subcondylar fracture.

Among the potential risks of nasotracheal intubation are nasal bleeding, sinusitis, bacteremia, accidental turbinectomy, and some other structural damages. Retropharyngeal dissection is reported as a very rare complication of nasotracheal intubation, mostly encountered in elective surgery patients. A case with traumatic subcondylar fracture of the mandible is presented here, which is suspected to be the cause of the nasopharyngeal dissection that was observed during attempted nasotracheal intubation.

Anterior pillarplasty: a modification in cleft palate repair.

After the primary repair of cleft palate, surgeons are frequently confronted with a short soft palate and a wide velopharyngeal space, both of which are known to diminish the quality of speech. We introduce a new modification of the primary repair of cleft palate that lengthens the soft palate and helps to reduce the volume of the velopharyngeal space. Ten patients younger than 12 months with nonsyndromic cleft palate were operated on with this technique. The incision at the cleft margin extended behind the uvula as a modification to the classic design of mucoperiosteal flaps. The sagittally divided mucosal layers of each anterior tonsillar pillar are sutured at the midline 1 cm posterior to the new uvula. The rate of postoperative fistula formation and other complications were evaluated postoperatively. One patient had a uvular and partly pillar detachment at the postoperative period. All other clefts healed without complication. The primary repair of the cleft palate with the anterior pillarplasty technique is a safe and easy-to-perform procedure. This modification can effectively reduce the transverse diameter of the velopharyngeal space and increase the anteroposterior length of the palate.

Benign chondroid syringoma: atypical presentation of a rare eccrine tumor.

Chondroid syringoma is a rare eccrine tumor that is often benign but has the potential for malignant transformation and distant metastasis. Histopathological analysis may not be definitive, and any patient with atypical features, an accelerated clinical course, or high suspicion for malignant transformation is a candidate for immediate surgical intervention and close follow-up. The purpose of this article is to review the clinical features of this rare tumor with a special emphasis on its atypical presentation.

Injury patterns and psychological traits of patients with self-inflicted wounds produced by punching glass.

BACKGROUND: Self-inflicted injuries are among the preventable forms of hand injury. Psychologic factors underlying these injuries have not been studied sufficiently. This study aims to reveal the extent of injury and the morbidity as well as the psychologic factors in a population of patients who intentionally injured themselves by punching glass. METHODS: Patients seen and treated for glass punching injuries during a 4.5-year period were reviewed. The demographic data included the extent of injury, postoperative hospitalization time, and full recovery time. Their psychologic traits were analyzed by two questionnaires (Symptom Distress Check List and State-Trait Anger Expression Inventory) and through a psychiatric interview. The results were compared with a sex- and age-matched control group with accidental hand injuries. RESULTS: The study group consisted of 36 patients. Mean age was 24.7 years. Most were men (n = 28), not married (n = 28), and living with their families. Half of them were unemployed. Twelve had only skin lacerations. The remaining 24 patients had a total of 45 tendon, 15 nerve, and 9 artery injuries. On an average, 46 days were required for full recovery. A second attempt of self-infliction was not reported. Twenty-one patients underwent questionnaires and psychiatric interview. The study group felt significantly higher levels of psychologic distress and hostility (p = 0.018 and p = 0.002, respectively). They also had higher levels of anger in daily life (p = 0.002). Clinical psychiatric evaluation failed to reveal any significant psychiatric disorder. CONCLUSION: Self-inflicted hand injuries increase the workload of emergency services and clinics involved in the treatment. Prevention is very difficult, especially when alcohol is not an underlying cause. A typical patient has hostile and disobedient characteristics and who easily expresses his anger. Happily, having suffered enough during their treatment these patients do not attempt a second self-infliction.

Aberrant perfusion of the serratus anterior muscle flap: report of two cases and a review of the literature.

Free serratus anterior muscle flap, classified as Mathes-Nahai type III, is a versatile and frequently preferred choice for soft tissue coverage of small to moderate-sized defects owing to its reliable circulation pattern; however, some anatomic variations in the flap vascularity can result in partial flap loss. Here we present two cases with free serratus anterior muscle transfer where the distalmost portion of the flap was not perfused by the thoracodorsal pedicle. The most likely explanation seems to be the large flap size and the lack of distal interconnections between lateral thoracic artery and thoracodorsal artery branches. Our clinical experience suggests that anatomic variations of serratus anterior muscle circulation might end up with distal perfusion loss if a large flap is to be harvested.

The Peruvian fisherman's knot: a new, simple, and versatile self-locking sliding knot.

BACKGROUND: In many plastic surgery operations that are undertaken through relatively small incisions resulting in deep-seated operating fields, sliding knots with a self-locking property are preferred by plastic surgeons for 3 reasons: simplicity, reliability, and versatility. We describe a new and versatile sliding knot that can be easily sledded and locked. METHODS: The technique of knot tying is described in detail as a stepwise approach with photographs. The main advantages of the Peruvian fisherman's knot are compared with other methods and summarized. RESULTS: In addition to its adjustment-related properties, knot security has been adequate with this knot as evidenced by its clinical performance and the authors' experiences to date. CONCLUSION: The Peruvian fisherman's knot is especially useful while working in deep seated operating fields through a small incision. Tension created during knot tying is adjustable, which makes it an ideal choice for various lifting procedures in plastic surgery.

Comparison of patient-prothesis mismatch after surgical aortic valve replacement and transcatheter aortic valve implantation.

BACKGROUND: The aim of this study is to analyze the outcomes and incidence of postoperative patient-prothesis mismatch after surgical aortic valve replacement using supra-annular bioprosthesis and transcatheter aortic valve implantation. METHODS: Between January 2012 and June 2015, a total of 73 patients (37 males, 36 females; mean age 71.8±5.7 years; range, 65 to 82 years) who underwent either surgical aortic valve replacement using supraannular bioprosthesis (n=36) or transcatheter aortic valve implantation (n=37) were included. Postoperative patient-prothesis mismatch was defined as absent, mild-to-moderate, and severe, if the indexed effective orifice area was >0.85 cm2/m2, >0.65 to <0.85 cm2/m2, and <0.65 cm2/m2, respectively. Both groups were compared in terms of patient-prothesis mismatch, postoperative outcomes, and mortality. RESULTS: The overall incidence of mild-to-moderate patient-prosthesis mismatch was 17.8% (13/73). No severe patient-prosthesis mismatch was observed. Mild-to-moderate patient-prosthesis mismatch was found in three patients (8.1%) in the transcatheter group and in 10 patients (27.8%) in the surgery group (p=0.035). Body surface area was the significant predictor of patient-prosthesis mismatch (p=0.007). Diameters of bioprosthetic valves in the surgery and transcatheter groups were 21.4±2 and 23.9±2.6 mm, respectively (p=0.002). Early mortality and pacemaker implantation rates were higher in the transcatheter group (p>0.05). Postoperative outcomes were similar between the groups. Mid-term mortality at a mean follow-up of 47.7±7.3 months was similar between the groups (p=0.158). CONCLUSION: In high-risk patients with severe aortic stenosis, patientprosthesis mismatch is mild-to-moderate after surgical aortic valve replacement and transcatheter aortic valve implantation; however, this has no effect on early mortality. Based on our study results, we suggest that the use of surgical approach for aortic valve replacement may prevent potential complications of transcatheter aortic valve implantation.