Mandibular reconstruction after hemimandibulectomy.

Ameloblastoma is a benign tumor of the mandible, which is not commonly diagnosed in the early stages. The extensive mandible resection may be needed for treatment. In this report, we present 6-year follow-up results of a patient who had undergone hemimandibulectomy and mandible reconstruction with free vascularized fibular flap, costochondral rib graft to restoration of the temporomandibular joint, and iliac bone graft to enhance the vertical height of the mandible. The long-term results are very satisfactory.

Expression of the endothelial thrombomodulin (TM) on the ischemic rat flap model: preliminary study.

Thrombomodulin (TM), a cell surface-expressed glycoprotein predominantly synthesized by vascular endothelial cells, is a critical cofactor for thrombin-medicated activation of protein C. TM thus has an impact on coagulation, inflammation, and fibrinolysis. In this study, we investigated expression of endothelial TM in the dorsal skin of the rat as an ischemic flap model. Twenty male Wistar rats weighing between 250 and 350 g were used in the study. Nine by 3-cm, full-thickness, caudally based random pattern dorsal skin flaps were elevated. The rats were randomized into 2 subgroups according to the evaluation time. Tissue blood flow of the skin flaps was measured 4 times (before the operation and on days 1, 3, and 7) at 1, 3, and 5 cm distal to the baseline of the skin flap. Skin flap samples including subcutaneous tissue were taken from killed rats at day 3 (n = 10) and 7 (n = 10) for histologic assessment. These samples were also taken from the midline at 1, 3, and 5 cm distal to the baseline of the skin flaps. The survival rate of the skin flaps was measured on day 7. According to the blood flow rate change, we found that there were significant differences between the 1-, 3-, and 5-cm samples throughout the experiment. The most profound change was that it was at 5 cm in which there was an initial pattern of reduced perfusion followed by cessation of perfusion. On the third day, positive immunoperoxidase staining specific for TM was detected in all the specimens of the skin biopsies taken from 1 and 3 cm. The 5-cm samples demonstrated very little evidence of necrosis and had negative immunoperoxidase staining for TM. The 1-cm samples were found to have preserved morphologic features present on days 3 and 7. The 3-cm samples showed no evidence of necrosis, though some of the capillary vessels were filled with aggregated blood cells. The vascular wall had negative peroxidase staining for endothelial TM. At 5 cm, there was clear evidence of necrosis, some found within the capillary vessels, which were filled with aggregated blood cells. These samples also had negative peroxidase staining for TM. On day 7, the survival rate of skin flaps was 45.35%. In this study, we demonstrate that tissue ischemia is an important factor, particularly in down-regulating TM transcription. TM depletion from the vascular cells and microthrombus formation occurred in the ischemic areas, playing an important role in secondary aggravation of tissue ischemia.

Comparison of regeneration results of prefabricated nerve graft, autogenous nerve graft, and vein graft in repair of nerve defects.

The purpose of this study was to evaluate the effectivity of prefabricated nerve grafts in the repairing nerve defect and to compare them with the autogenous nerve graft and vein graft. Four groups were created, each containing 10 rats. First, nerve prefabrication was carried out in groups I and II during 8 weeks. For this purpose, jugular vein graft was sutured to the epineural windows on the peroneal and tibial nerve at the right side in an end-to-side fashion. To create neurotrophic stimulus, partial incision was performed on the nerves in group I, and gene therapy was performed by plasmid injecting to the adjacent muscles in group II. At the end of the eighth week, prefabricated nerve grafts, jugular vein, and the axons passing through it were taken. Then, gap was created on the left peroneal nerve in all groups. Defect on the peroneal nerve was repaired by using the prefabricated nerve grafts in groups I and II, the autogenous nerve graft in group III, and the vein in group IV. Assessment of nerve regeneration was performed by using electromyography. Morphological assessment was performed after follow-up period. According to electrophysiological and morphological results, the results of first three groups were similar. There was no statistically significant difference between three groups. Prefabricated nerve graft is as effective as autogenous nerve graft, and it can be used in the repair of nerve defects as autogenous nerve graft as an alternative.

[Use of double flaps in high-voltage electrical injury of scalp and calvaria: case report]. / Saçli deri ve kalvaryumun yüksek voltajli elektrik yaralanmasinda çift flep kullanimi: Olgu sunumu.

A 15-year-old boy sustained a high-voltage electrical injury with full-thickness scalp and calvarial bone necrosis in the parieto-occipital region. While necrotic soft tissues were debrided on the fifth day of injury, the devitalized calvaria was preserved. Bilayered coverage of the necrotic bone was achieved by transposition of 'bipedicled pericranial flap' and 'bipedicled scalp flap'. No complication was observed in the postoperative period. A bone resorption area, smaller than the original necrotic bone area, was observed in the long-term follow-ups.

Reconstruction of distal forefoot burn defect with retrograde medial plantar flap.

Burn reconstruction of forefoot remains as a difficult challenge, because the local flap alternatives are limited. We evaluated the efficiency of distally based medial plantar fasciocutaneous island flap in the coverage of forefoot defects resulting from release of toe contracture and burn debridement. Four patients with toe contractures and two patients with third degree burn in forefoot were treated between June 2004 and February 2006. The mean follow-up period was 10.4 months. The flaps were elevated as with a fasciocutaneous base on the distal medial plantar artery. The dimensions of the flaps ranged from 4cmx3cm to 5cmx4cm. The skin over the pedicle was included as a part of flap in three cases. Concomitant vein of the pedicle was anastomosed with the first plantar digital vein in four cases. In the early postoperative period, one flap used to cover third degree burn due to high-voltage electric injury was lost completely. We concluded that this flap was an appropriate alternative reconstructive option for the forefoot defect. Including skin and subcutaneous tissue over the pedicle to flap protects the pedicle against kinking and compression. Venous supercharging of the flap improves venous drainage.

Are reverse flow fasciocutaneous flaps an appropriate option for the reconstruction of severe postburn lower extremity contractures?

Full thickness burns involving the lower extremity can result in severe contractures, which impair extremity functions if they are not managed with proper treatment and rehabilitation. After release of postburn contracture of the knee, ankle, and metatarsophalangeal joints, defects often require coverage by flaps. Twelve distally based reverse flow flaps were performed for lower-extremity reconstruction after release of postburn flexion contractures. All of the patients were male and their age ranged from 20 to 23 years, with a mean age of 21. After the release of the contractures, 3 flaps were used based on the location of the contractures. The reverse flow anterolateral thigh flap was used for knee reconstruction (n = 4, 33%). The reverse flow sural flap was used for ankle reconstruction (n = 4, 33%), and the reverse flow medial plantar flap was used for metatarsophalangeal reconstruction (n = 4, 33%). The sizes of the flap varied from 2 to 17 cm wide and 3 to 18 cm in length. All defects were covered successfully. Reverse fasciocutaneous tissue transfer to reconstruct the soft tissue defects provide early motion. Sufficient contracture release is achieved without displacement of anatomic landmarks. The reverse-flow flap is a reasonable and reliable choice for each joint level in the lower extremity.

Soft tissue necrosis following using calcium phosphate cement in calcaneal bone cyst: case report.

Calcium phosphate cements have received widespread attention for their possible role as bone-grafting material and bone fillers in skeletal defects. They were evaluated as a biomaterial in many aspects. No serious harmful effects such as foreign body reaction and tissue necrosis against to calcium phosphate cements have been reported yet. They were accepted as highly biocompatible materials. In this paper, we represent a patient who had soft tissue necrosis around lateral malleolar region, following using percutaneous calcium phosphate cement as a filler bone substitute in calcaneus bone cyst. The possible mechanisms were discussed.

Effects of nebivolol on skin flap survival: A randomized experimental study in rats.

BACKGROUND: Skin flaps are among the basic treatment options in the reconstruction of soft tissue defects. To improve skin flap survival, a variety of methods, including pharmacologic agents, have been investigated. The effectiveness of anticoagulants, antioxidants, anti-inflammatory drugs, and vasodilatory drugs in improving flap survival has been studied. Nebivolol is a new-generation selective ß1-adrenoreceptor blocking agent that has vasodilatory, antithrombotic, antioxidative, and anti- inflammatory effects. OBJECTIVE: The aim of this experimental study was to investigate the effects of nebivolol (50 mg/kg/d) on random pattern skin flap survival in rats. METHODS: Male Wistar rats weighing 290 to 310 g were randomly divided into 2 groups-the nebivolol group and the control group. Random patterned, caudally-based, ~3 × 10-cm skin flaps were elevated on the back of each rat. In the nebivolol group, nebivolol 50 mg/kg/d (1 mL, of a racemic solution of nebivolol) was administered orally 2 days before surgery to reach steady-state drug blood concentrations and was continued for 6 days. In the control group, 1 mL/d of sterile saline solution was orally administered 2 days before surgery and was continued for 6 days. To observe the effects of nebivolol, cutaneous blood flow was examined using a laser Doppler flow-meter before and after surgery on days 1, 3, 5, and 7, and flap tissue, malondialdehyde (MDA) and glutathione (GSH) concentrations, and superoxide dismutase (SOD) activity were measured 7 days postsurgery. Flap viability was evaluated 7 days after surgery by measuring necrotic flap area and total flap area. RESULTS: All 20 rats (nebivolol group, n = 10; control group, n = 10) survived throughout the study period. Mean (SD) MDA concentration was significantly lower in the nebivolol group than in the control group (69.25 [5.82] vs 77.67 [6.87] nmol/g tissue; P = 0.009). GSH concentration was significantly higher in the nebivolol group than in the control group (2.14 [0.15] vs 1.88 [0.22] nmol/mg tissue; P = 0.004). SOD activity was significantly greater in the nebivolol group than in the control group (49.28 [5.49] vs 42.09 [4.95] U/g tissue; P = 0.007). The percentage of the flap that was necrotic was significantly lower in the nebivolol group than in the control group (40.27 [4.08] vs 48.87 [6.35]; P = 0.007). CONCLUSIONS: This small, experimental, in vivo animal study found that nebivolol was associated with reduced necrotic random pattern skin flap area. Further studies are needed to clarify these findings.

Effort-related compression of median and ulnar nerves as a result of reversed three-headed and hypertrophied palmaris longus muscle with extension of Guyon's canal.

We explored a swelling on the anterior surface of the right distal forearm of a 21-year-old right-handed male soldier and effort-induced symptoms of median and ulnar nerve compression that showed a reversed, three-headed and hypertrophied palmaris longus muscle with extension of Guyon's canal.

Use of free dorsoulnar perforator flap in the treatment of postburn contractures of the fingers.

BACKGROUND: Burns of the hand cause not only the impairment of hand function but also cosmetic deformity. Cases with dysfunctional hands with severe contractures increase if rehabilitation of the acutely burned hand is not done properly. PURPOSE: We present the use of free dorsoulnar perforator flap in the treatment of postburn contractures as an alternative when local flaps cannot be used. METHODS: Free dorsoulnar perforator flap was used in the treatment of seven hands with postburn contracture. Five of them had multiple digital postburn flexion contractures. Combined use of cross-finger and side finger transposition flaps was preferred when the adjacent finger was suitable for being cross-finger flap donor. When the adjacent finger was not suitable for being cross-finger flap donor, the free dorsoulnar perforator flap was preferred. Two of the patients had postburn web contractures. Free dorsoulnar perforator flap was used to release the web and to form a new web commissure. CONCLUSION: The free dorsoulnar perforator flap could be a good alternative to cover the defects created with the hand contracture release.

Use of rhomboid flap and double Z-plasty technique in the treatment of chronic postburn contractures.

BACKGROUND: Multiple reconstructive methods have been used for the treatment of postburn scar contractures including skin grafting, geometric relaxation techniques, local flaps and free flaps. PURPOSE: In the present study, the authors evaluated efficiency of the use of rhomboid flap and double Z-plasty technique in the treatment of chronic postburn contractures. METHODS: Twelve white male with postburn scar contracture were treated using rhomboid and double Z-plasty technique. The cause of burn, duration of contracture, postoperative follow-up period, preoperative and postoperative motion lag of joints and improvement in motion were recorded. CONCLUSIONS: All operations were successful. Severe contracture lines crossing flexion folds can be released effectively by using rhomboid flap and double Z-plasty technique without distorting the specialized flexion areas and with broken scar lines which is essential to avoid from recurrence.

Comparison of the rates of elongation provided by multiple smaller rhomboid flaps and larger single rhomboid flap--an experimental study.

BACKGROUND: The rhomboid flap is one of the geometric relaxation techniques used for releasing burn scar contractures. PURPOSE: In the present study, we evaluated the question; 'which is better: one larger rhomboid flap or a series of multiple smaller rhomboid flaps?' METHODS: Ten male Wistar rats each weighing 250-300 g were used. In the groups, 2.5 cm of the inguinal region was used. Two 1 cm long rhomboid flaps with spaced by 0.5 cm were used in the right side and a single 2.5 cm long rhomboid flap was used in the left side. CONCLUSION: An elongation by using single larger rhomboid flap (66%) is significantly bigger than an elongation by using multiple smaller rhomboid flaps (26%) (p<0.01).

Use of dorsal ulnar neurocutaneous island flap in the treatment of chronic postburn palmar contractures.

In the present study, the authors evaluated efficiency of the "dorsal ulnar neurocutaneous island flap" in the coverage of palmar defects resulting from radical release of selected chronic postburn contractures. Eight white male hands with palmar contracture were treated with this flap between November 2001 and December 2003. The mean follow-up period was 11.6 months. The flap, which was planned on the ulnar aspect of the forearm and the hand, is transferred to the palmar defect. The subcutaneous pedicle of the flap was skin-grafted to avoid tension. All operations were successful. Distal flap necrosis that healed by secondary intention was observed in one of the eight flaps. Seventy-five degrees was the maximum improvement in metacarpophalangeal (MP) joint extension achieved in the little finger. Grasp function of the hand dramatically improved and the bulk of the flap did not interfere with grasping. No recurrent palmar contracture was observed. The authors concluded that the dorsoulnar neurocutaneous island flap can be used effectively in the treatment of postburn palmar contractures. The safety of the flap can be enhanced by grafting the intervening skin between the pivot point of the flap and the palmar defect.

Comparison of silver-coated dressing (Acticoat), chlorhexidine acetate 0.5% (Bactigrass), and fusidic acid 2% (Fucidin) for topical antibacterial effect in methicillin-resistant Staphylococci-contaminated, full-skin thickness rat burn wounds.

Acticoat, chlorhexidine acetate 0.5%, and fusidic acid 2% were compared to assess the antibacterial effect of an application on experimental 15% BSA, full-thickness burn wounds in rats swabbed 24 h earlier with a 10(8) standard strain of methicillin-resistant Staphylococci. The swabbed organism was recovered from the eschar of all groups except the fusidic acid group. While there were significant differences between treatment groups and control group, the mean eschar concentrations did not differ significantly between the Acticoat and chlorhexidine acetate groups, but there were significant differences between the fusidic acid group and the other treatment groups. There were no statistically significant differences between treatment groups, and between control group and the chlorhexidine acetate group regarding recovery of the seeded organism from muscle, but there were significant differences between the control group and Acticoat group, and between control the group and the fusidic acid group. While no systemic spread was seen in the treatment groups, it was seen in six animals in the control group. The animal data suggest that fusidic acid is the most effective agent in the treatment of methicillin-resistant Staphylococcus aureus-contaminated burn wounds, and Acticoat is a choice of treatment with the particular advantage of limiting the frequency of replacement of the dressing.

Comparison of silver-coated dressing (Acticoat), chlorhexidine acetate 0.5% (Bactigrass), and silver sulfadiazine 1% (Silverdin) for topical antibacterial effect in Pseudomonas aeruginosa-contaminated, full-skin thickness burn wounds in rats.

Acticoat (Smith and Nephew, Istanbul, Turkey), chlorhexidine acetate 0.5%, and silver sulfadiazine 1% were compared to assess the antibacterial effect of their application on experimental burn wounds in contaminated with Pseudomonas aeruginosa in rats. All treatment modalities were effective against P. aeruginosa because there were significant differences between treatment groups and control groups. The mean eschar concentrations did not differ significantly between Acticoat and chlorhexidine acetate groups, but there were significant differences between the silver sulfadiazine group and the other treatment groups, indicating that silver sulfadiazine significantly eliminated P. aeruginosa more effectively in the tissues than did the other two agents. All treatment modalities were sufficient to prevent the P. aeruginosa from invading to the muscle and from causing systemic infection. In conclusion, silver sulfadiazine is the most effective agent in the treatment of the P. aeruginosa-contaminated burn wounds; Acticoat can be considered as a treatment choice because of its peculiar ability of limiting the frequency of replacing wound dressings.

Reconstruction of a complex intercanthal defect with triple advancement flaps.

A complex intercanthal skin defect, created by resection of a squamous cell carcinoma localised in the nasal root of a 52-year-old man, was successfully reconstructed using three axial pattern advancement flaps raised from the nasal dorsum and paranasal areas.

The evaluation of nosocomial infection during 1-year-period in the burn unit of a training hospital in Istanbul, Turkey.

An analysis of the burned patients, admitted to our eight bed burn unit and treated between 1 January and 31 December 2000, was performed. Prevalence, etiologic agents, length of hospitalization, cost of treatment and mortality rates caused by nosocomial infections (NIs) were studied. The study included 63 patients. Eighteen of these (Group-A) had 24 NI episodes. The most common NI observed was burn-wound infection (58.3%), followed by bacteraemia-sepsis (16.7%). NIs were not detected in the rest at all (Group B). The mean length of hospitalization was 38.5+/-19.7 days in Group A, and 20.3+/-7.6 days in Group B. The mean total burned surface area (TBSA) was 43+/-21 in Group A and 29+/-18 in Group B, while the most important independent risk factor for NI was TBSA in burned patients (OR, 1.08; CI(95), 0.93-1.24). NI prolonged the mean hospital stay to 18 days and increased the cost of treatment by 502 US dollars. The most common bacteria isolated was Pseudomonas aeruginosa (41.7%) and the second was methicillin resistant Staphylococcus aureus (MRSA-25.0%). All of the NI-free patients survived, while, five (28.5%) patients with NI died (P<0.01). These findings emphasized the need for careful disinfection and conscientious contact control procedures in areas that serve immunosupressed individuals, such as burned patients.

Carbon dioxide laser resurfacing and thin skin grafting in the treatment of "stable and recalcitrant" vitiligo.

Various surgical methods have been used in the treatment of small stable vitiliginous areas, but there is no established surgical approach for larger vitiligo areas and therapy-resistant anatomic sites, such as the hands. Two years ago, we successfully treated large burn scar depigmentation areas at different anatomic sites using carbon dioxide laser resurfacing and thin (0.2 to 0.3 mm) skin grafting. The purpose of this study was to investigate the effectiveness of our method in treating large, stable, and recalcitrant vitiligo areas. Thirteen anatomic sites of seven male patients, whose ages ranged from 20 to 22 years, were treated. The locations of the treated areas were as follows: seven areas on the dorsum of the hands, two areas on the forearms, two areas in the pretibial region, one area on the lateral thigh, and one area in the presternal region. The surface area of treated vitiligo sites ranged from 0.5 to 6 percent of total body surface area (mean, 2.5 percent). Skin graft take was excellent in all patients except for one. The follow-up period for these patients ranged from 6 to 18 months, with an average follow-up period of 14 months. Early and complete repigmentation was achieved and the color match was good or excellent in all patients. No depigmentation occurred again in the treated areas or graft donor sites. In conclusion, with careful patient selection and delicate surgical technique, our method was effective in treating large areas of vitiligo over the extremities and dorsum of hands, which were refractory to other therapies and could not be hidden.

Effect of various nerve decompression procedures on the functions of distal limbs in streptozotocin-induced diabetic rats: further optimism in diabetic neuropathy.

It is known that diabetic neuropathy is the result of endoneurial edema caused by various biochemical reactions triggered by hyperglycemia. This sequence of events can cause cessation of circulation at the perineurial level, or the tough layer, which is not resilient enough to spread intraneural pressure. Internal and external limiting structures create a double crush phenomenon to the nerve structure. Decompression of the nerve trunk at separate levels is one of the adjuncts to the overall treatment plan for diabetic neuropathy. In this study, the right sciatic nerves of 30 rats with streptozotocin-induced diabetes were used; three groups were created. In the control group, the sciatic nerves were explored and dissected only. In group II, tarsal tunnel release was performed and accompanied by epineurotomy of the sciatic nerve and its peroneal and tibial extensions. In group III, in addition to the procedures performed in group II, perineural sheaths, exposed through the epineurotomy sites at both the peroneal and tibial nerves, were incised for decompression of the fascicles. Improvement in diabetic neuropathy was evaluated by using footprint parameters. The last print length values, estimated according to the 38-month measurements, were 26.1 +/- 0.12 mm in the control group, 23.2 +/- 0.07 mm in group II, and 22.2 +/- 0.1 mm in group III. The toe spread and intermediate toe spread values of the groups were parallel to improvements in print lengths throughout the study. The best improvement was observed in the perineurotomy group. Finally, an electron microscopic study revealed variable degenerative changes in all groups, but they were milder in groups II and III. This experimental study reveals that adding internal decompression to external release doubled the effect in reducing derangement in the sciatic nerves of the rats and, in the authors' opinion, offers cause for further optimism in the treatment of diabetic neuropathy.

Comparison of silver sulfadiazine 1%, mupirocin 2%, and fusidic acid 2% for topical antibacterial effect in methicillin-resistant staphylococci-infected, full-skin thickness rat burn wounds.

Silver sulfadiazine 1%, mupirocin 2%, and fusidic acid 2% were compared to assess the antibacterial effect of a once-daily application on experimental rat 15% full-skin thickness burn wounds seeded 24 hours earlier with a 10 standard strain of methicillin-resistant staphylococci. The quantitative counts of seeded organism in burn eschar and subjacent muscle were determined at postburn day 7, beside the cultures of blood and lung biopsies. All tested topical agents were equally effective against methicillin-resistant in reducing local burn wound bacterial count and preventing systemic infection.