Effect of decorin protein administration on rat sciatic nerve injury: an experimental study.

INTRODUCTION: Peripheral nerve traumas are common injuries in young adult population. The myriad of techniques and medications have been defined to obtain better recovery but none of them was proved to have superior effect. This study aims to determine the anti-fibrotic effect of the decorin on sciatic nerve injury in order to enhance functional outcome. MATERIALS AND METHODS: 24 12-week-old male Sprague-Dawley rats (350-400 gr) were divided into four groups. The sciatic nerve was dissected and exposed; a full-thickness laceration was created 1.5 cm proximal to the bifurcation point and 1.5 cm distal to where it originated from the lumbosacral plexus. Motor and sensory tests were conducted before and after the operations for evaluating the nerve healing. RESULTS: There was a statistically significant difference between DCN bolus and PBS bolus group. (p<0.0001, p<0.05) in neuromotor tests. Increase of the latency was significantly lower in DCN bolus and infusion group when compared with the PBS bolus group. (p<0,001). All operated gastrocnemius muscles were atrophic compared with the contralateral side. The differences between the averages in the sciatic functional index, the improvement of the DCN infusion group was 8.6 units better than the PBS group and 4.4 units better than the DCN bolus group. When the amount of stimulation was 10 mV at the proximal segment in electromyography, there was no significant difference between the DCN bolus and sham groups. (p> 0.05, p = 0.6623). CONCLUSION: Decorin protein reduces the fibrosis and enhances the motor and sensory recovery both clinically and histologically. Despite the high cost, short half-life and production issues, this protein could be administered after the microsurgical repair but more studies are required to overcome the limitations.

Necrotising fasciitis or pyoderma gangrenosum: A fatal dilemma.

Necrotising fasciitis (NF) is mostly a polymicrobial, severe soft tissue infection that progresses rapidly, penetrating through the subcutaneous tissue to the fascial planes and the muscles. The pyoderma gangrenosum (PG), on the other hand, is a rare, rapidly progressive (except for the post-surgical PG), autoinflammatory ulcerative skin and soft tissue condition. In this study, we tried to emphasise the importance of diagnosing the NF as well as the PG. Although these two clinical presentations have some standard features, awareness of different symptoms in detail affect the outcome. Any surgical discipline can face NF or PG and, therefore, should be aware of them to decrease the mortality rate. Forty-five patients with NF and PG who were treated between January 2008 and October 2018 were included in the study and evaluated retrospectively for age, sex, localisation, onset of symptoms and diagnosis, predisposing factors, characteristics of tissue defects, laboratory findings, Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) scores, isolated microbiological agents, surgical intervention, and mortality rate. Demographic, laboratory, and clinical data were analysed. Among these 45 patients, 14 patients had PG, and 31 patients had NF. The mean age and SD for the NF and PG groups were 50.80 ± 17.67 and 50.78 ± 12.72, respectively. Five patients had rheumatological disorders; four patients had diabetes mellitus (DM) in the PG group. Males had higher risk than females in NF (odds ratio [OR] = 0.077, 95% confidence interval [CI] 0.017-0.34), and females had higher risk in PG (relative risk [RR] = 5). We compared the LRINEC score of NF patients with PG patients. The mean value of this score was 4.53 for PG patients, and 6.06 for NF patients. Fifteen patients (33.3%) had a radiological evaluation. MRI, CT, and USI were used as imaging modalities. Necrotising fasciitis and PG are two distinct entities that are in general difficult to distinguish. Therefore, differential diagnosis and rapid treatment are crucial for lowering the mortality rate.

Is Histological Evaluation of Reduction Mammaplasty Specimens Worthwhile?

BACKGROUND: Reduction mammaplasty (RM) is one of the most common plastic surgery procedures. Despite its cost, the total number of RM procedures continues to increase every year. OBJECTIVES: The purpose of this study is to review the prevalence of benign and malignant breast lesions among women who live in the Aegean region of Turkey, based on our university hospital's records and to compare our results with those in the literature. METHODS: Seven hundred and thirty-three consecutive female patients who underwent RM between January 2003 and January 2017 in the Department of Plastic, Reconstructive, and Aesthetic Surgery were included in this study. RESULTS: One hundred and sixty-five patients (23.4%) had preoperative breast imaging results. According to the Breast Imaging Reporting and Data System (BIRADS), most of these patients had BI-RADS-2 and BIRADS-1 findings (41.21% and 40%, respectively). Fibrocystic changes were the most common lesions (81.3%). Sixty-eight patients (9.6%) had normal breast tissue on the right side and 34 patients (4.8%) had the same on the left side. Five patients (0.71%) had atypical ductal hyperplasia and no atypical lobular carcinoma. Four patients (0.56%) had occult breast cancer and one patient (0.14%) had benign phyllodes tumor. CONCLUSIONS: RM is a good opportunity to detect proliferative lesions and occult breast cancer. While meeting the patient's aesthetic desires, the plastic surgeon should consider for histopathological evaluation. We suggest that every part of the breast tissue should be sent to pathological examination regardless of the weight of the specimen. Even if health insurance does not cover its cost, patients should be informed about the importance of this process.

The functional results of acute nerve grafting in traumatic sciatic nerve injuries.

BACKGROUND: The sciatic and peroneal nerves are the most frequently injured in lower extremities, followed by tibial and femoral nerves. The aim of this study is to evaluate the functional results of acute nerve grafting in traumatic sciatic nerve injuries. METHODS: A total of 9 patients with sciatic nerve defect were treated with primary nerve grafting. The mean age was 31.7 years. The etiologic factors were gunshot wounds, traffic accident, and penetrating trauma. RESULTS: All of the patients had sciatic nerve defects ranging from 3.4 to 13.6 cm. The follow-up period ranged between 25 and 84 months. The tibial nerve motor function was "good" or "very good" (M3-M4) in 5 patients (55.6%). The plantar flexion was not sufficient for the rest of the patients. The peroneal nerve motor function was also "good" and "very good" in 3 patients (33.3%). CONCLUSION: The functional results of the acute nerve grafting of the sciatic nerve within the first week after the injury are poorer than reported in the related literature. This protocol should only be applied to select patients who have adequate soft tissue coverage and healthy nerve endings.

Necrotising fasciitis in the central part of the body: diagnosis, management and review of the literature.

Necrotising fasciitis (NF) is characterised by rapidly spreading necrosis of the soft tissue and fascia. It is rare but can be fatal when not managed properly. The aim of this study is to evaluate the diagnosis, treatment and results such as mortality, morbidity and reconstructive options of NF localised in the central part of the body. The main goal is to emphasise upon the clinical symptoms for early diagnosis which is the most important factor in saving the lives of these patients. Between January 2000 and December 2010, 30 patients with NF localised in central parts of the body were treated. Six of the patients were female (20%) and the others were male (80%). The mean age was 54·03 years (ranged between 26 and 83 years). The average time from the onset of symptoms to diagnosis was 6 days, ranging from 2 to 11 days. The localisation of NF was perineum in 24 patients (80%); inguinal and thigh region in 5 patients (16·7); and back in 1 patient (3·3%). The hospitalisation time was varying between 17 and 32 days (mean 23 days). Six patients (20%) died and 24 patients (80%) survived. All non-survivors had risk factors and secondary comorbidities such as immunosuppression, chronic cardiac failure, and diabetes with high glucose level. Survivors also underwent repeated debridement operation 2-4 times. Reconstructive procedures were split-thickness skin graft (STSG) in eight patients (33·3%), fasciocutaneous flaps in four patients (16·6%), fasciocutaneous flap + STSG in six patients (25%), scrotal flap + STSG in two patients (6·6%), scrotal flap in two patients (6·6%) and musculocutaneous flap + STSG in one patient (3·3%). There was no major complication such as flap and graft loss, after reconstructive procedures. Early diagnosis of NF may be the lifesaving factor. Amuputation can save the patient's life in the case of NF in the extremities; however, this is not an option for NF in central parts of the body. In these cases, when NF is suspected, early debridement of necrotic tissues should be performed. As soon as the infection and the spread of the necrosis are controlled, reconstruction should be considered.

Keloid formation after circumcision and its treatment.

Circumcision is performed in many communities around the world for either medical, ethnic, or religious issues. It is a safe procedure when it is performed by a fully trained surgeon. However, complications such as bleeding, infection, diminished penile sensation, urethral injury and amputation of the glans are occasionally seen. Keloid is the result of excessive deposition of collagen in the dermis and subcutaneous tissues. It usually develops at the site of trauma or surgical injuries. Keloid formation on the penis is a very rare condition. In this study, we present a case of keloid formation after circumcision and review the related literature.

[Necrotizing fasciitis: diagnosis, treatment and review of the literature]. / Nekrotizan fasiit: Tani, tedavi ve literatürün gözden geçirilmesi.

BACKGROUND: Necrotizing fasciitis (NF) is characterized by rapidly spreading necrosis of the soft tissue and fascia. It is rare, but can be fatal if not managed properly. The aim of this study was to discuss the morbidity and mortality in NF patients in terms of evaluating early diagnostic techniques and reconstructive options. METHODS: Sixty-eight patients (59 male, 9 female; mean age 55.9 years; range 28 to 88 years) with localized NF who were treated between 2000 and 2010 were assessed retrospectively for age, sex, localization, time elapsed between onset of symptoms and diagnosis, predisposing factors, characteristics of tissue defects, isolated microbiological agents, surgical intervention, complications, and mortality rate. RESULTS: In 52 patients (76.4%), comorbidities such as diabetes, obesity, smoking, and corticosteroid use were present. The most common localization was the perineum and inguinal region (n=48, 70.5%). Time elapsed between onset of symptoms and diagnosis was 6.2 days (1-12 days). The mean size of tissue defect after the first debridement procedure was 54.2 cm2 (28-82 cm2). The most common isolated microbiological agents were as follows: Escherichia coli, Enterococci, and Pseudomonas aeruginosa. Polymicrobial infections were encountered in 54 patients (79.4%). The most common reconstructive procedures were fasciocutaneous flap + split-thickness skin grafting (n=39, 57.3%). No major complication was observed; minor complications included wound dehiscence and partial graft loss. The mortality rate was 13.2% (n=9). CONCLUSION: The early diagnosis of NF may be lifesaving. When NF is suspected, early debridement of necrotic tissues should be performed. As soon as the infection and the spread of the necrosis are controlled, reconstruction should be considered.

The versatile use of temporoparietal fascial flap.

BACKGROUND: The pedicled or free temporoparietal fascial has been used in many areas, especially in head and neck reconstruction. This thin, pliable, highly vascularized flap may be also transferred as a carrier of subjacent bone or overlying skin. OBJECTIVE: The aim of this study is to report our experience in versatile use of temporoparietal fascial flap (TPFF) and discuss the surgical anatomy and technique. PATIENTS AND METHODS: A total number of 57 TPFFs have been used in periorbital, mid-facial, auricular, and tracheal reconstruction due to tumor resection, trauma, and congenital ear deformities. RESULTS: All the flaps were successfully transferred without any major complication. The cosmetic results were quite satisfactory to all patients. CONCLUSION: The advantages and minimal donor site morbidity of TPPF makes this flap a good choice in many reconstructive procedures.

Surgical management of hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, relapsing inflammatory disease of skin, characterized by recurrent draining sinuses and abscesses, predominantly in skin folds carrying terminal hairs and apocrine glands. METHOD: This study reviewed 54 sites in 27 patients with moderate to extensive chronic inflammatory skin lesions treated surgically in our hospital from 2004 through 2009, with a follow-up of at least 6 months. RESULT: A total number of 54 operative procedures were performed during the study period with 42% (23 sites) involving the axilla, 20% (11 sites) involving the gluteal area, %24 (13 sites) involving the perineal area and 12% (7 sites) involving the inguinal region. CONCLUSION: Conservative treatment methods have little or no effects especially on gluteal, perineal/perianal, axillary hidradenitis suppurativa. The morbidity associated with the established form of this disease is significant, and the only successful treatment is wide surgical excision.

A comparison of vascularized fibular flap and iliac crest flap for mandibular reconstruction.

Segmental mandibular defects, which are caused either by ablative surgery or trauma, are usually accompanied by different degrees of skin, soft tissue or mucosa losses. The reconstruction of such defects requires complicated surgical procedures. An ideal mandibular reconstruction method must support the insertion osseointegrated dental implants which is necessary for total oral rehabilitation. The soft tissue defect should also be reconstructed if it accompanies the bony defect. We performed 37 mandibular reconstructions using either vascularized iliac crest flap or fibula flap. Sixteen of 24 patients who underwent mandibular reconstruction using iliac crest flap, and 3 of 13 patients who has been reconstructed with fibula flaps, had mandibular defects involving skin and/or mucosa. Both techniques were compared regarding patients records such as hospital stay, operation time, defect size, etiopathogenesis, skin paddle, blood transfusion, and complication rates. Self-assessment questionnaires were also used to evaluate aesthetic and functional results. When 2 different mandibular reconstruction techniques are compared regarding patient records, the complication rate of fibula flap was less than the iliac crest flap. Functional and aesthetic results also showed that oral continence, social activities, and facial appearance rates of fibula flap were superior to iliac crest flap. Lower complication rates of fibula flap group may be associated with patients' higher satisfaction rate. Both flaps are commonly used in mandibular reconstruction, however, many parameters including defect localization, defect size, presence of soft tissue defect should be considered.

Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction.

Various alloplastic and autogenous materials have been used for dorsal nasal augmentation. Bone and cartilage autografts commonly are used. We used rib cartilage graft for dorsal nasal augmentation. The aim of this study was to investigate the long-term outcomes and patient satisfaction of dorsal nasal augmentation with rib cartilage grafts. Thirty-eight patients who had been operated on for dorsal nasal augmentation with rib cartilage graft were included in this study. Operation times, postoperative complications, and revision surgery were investigated by using hospital records. Anthropometric measurements were used for determining the resorption rate of cartilage graft. A questionnaire was used for the evaluation of long-term patient satisfaction. Evaluation of the patients' records showed that average operation time was 116 minutes and there were no complications such aspleural damage. The mean follow-up period was 27.4 months. Nine patients required secondary nasal surgery, including soft tissue augmentation (n = 1), nasal tip revision (n = 3), and reshaping the cartilage graft (n = 5). Long-term anthropometric measurements, comparing preoperative and postoperative values, documented increases in both tip projection (4.2%) and nasal length (1.2%) and an increase in nasolabial angle of 8.2 degrees . Eighty-one percent of the patients who answered the questionnaire rated the nasal size as normal. Nasal symmetry and nasal shape were good in 75% and 66% of the patients, respectively. Results of the rib cartilage grafts that are used for dorsal nasal augmentation are satisfactory for the patients and resorption rates are not high enough to change the shape of the nose.

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.

Repair of fractures of the orbital floor with porous polyethylene implants.

Our main aim was to evaluate the long-term results after reconstruction of the orbital floor with porous polyethylene implants. Twenty-six patients with fractures of the orbital floor were included in the study. The main cause of fractures was road crashes. They also complained of enophthalmos (n=19), diplopia (n=21), limited extrinsic ocular motility (n=17), impairment of the infraorbital nerve (n=18), and hypoglobus (n=9). All the fractures were reconstructed with thin and ultra-thin porous polyethylene sheets. No implants extruded and there were no signs of inflammatory reaction against the porous polyethylene. The symptoms were treated in 14 patients with enophthalmos, 18 with diplopia, 16 with limited extrinsic ocular motility, 14 with impairment of the infraorbital nerve and 8 with hypoglobus. Postoperative infections in four patients were treated with systemic antibiotics. Persistent ectropion was present in two patients. Porous polyethylene sheets are reliable, safe and effective implants and may be used for reconstruction of the orbital floor fracture with no donor site morbidity or need to fix implant.

Chemical burn in domestic setting with an uncommon agent: hydrofluoric acid.

Chemical burns, in particular because of hydrofluoric acid, are not common in the pediatric emergency department. Here, we describe an infant presenting with digital ischemic findings owing to late diagnosis of hydrofluoric acid splash in domestic setting.

Surgical management of ameloblastoma in the mandible: Segmental mandibulectomy and immediate reconstruction with free fibula or deep circumflex iliac artery flap (evaluation of the long-term esthetic and functional results).

PURPOSE: Ameloblastoma is responsible for 1% of all the oral and maxillomandibular cysts and tumors. It is odontogenic in origin and benign in nature but it has a high percentage of local recurrence rate and possible malignant development when treated inadequately. With the advancement of craniofacial surgical techniques, use of free flaps for mandibular reconstruction, and dental rehabilitation (such as osseointegration), the segmental mandibulectomy and immediate reconstruction with free flaps are beginning to be used more effectively for the treatment of the mandibular ameloblastoma. The aim of this article is to evaluate the clinical results of the patients with mandibular ameloblastoma who were treated with segmental mandibulectomy and immediate reconstruction with free flaps. PATIENTS AND METHODS: We present 11 patients who had segmental mandibulectomy and immediate reconstruction with free deep circumflex iliac artery or fibular flap for treatment of mandibular ameloblastoma. The average age of the patients was 25.4 years (range, 18-38 years). The patients were followed up for a mean of 29.3 months (range, 17-38 months). The functional and esthetic results were also evaluated by using a questionnaire in the long term. The questionnaire consisted of questions addressing oral continence, diet, social activities, speech, and facial appearance. RESULTS: All flaps survived totally. Recurrence was not detected during the follow-up period. It was found that all patients had good esthetic and functional results after immediate reconstruction. The social activities of patients also were not affected after treatment. CONCLUSIONS: We experienced that segmental mandibulectomy with safe borders and immediate reconstruction with free fibula flap or deep circumflex iliac artery (DCIA) flap is an ideal treatment method for mandibular ameloblastoma. The functional and esthetic results are also detected as very satisfactory for the patients.

Total lower eyelid reconstruction using paranasal flap.

The main aim of this study is to evaluate the advantages, disadvantages, and aesthetic results of the total lower eyelid reconstruction with paranasal flap. The other reconstruction methods are also revisited.Ten patients, who were operated for the reconstruction of total lower eyelid defects between November, 1999 and April, 2005 in our department were included in this study. The total lower eyelid defects of all patients were reconstructed using paranasal flap for anterior lamella and chondromucosal, chondrocutaneous or mucosal graft for posterior lamella. Follow-up time was ranged between 3-35 months. The advantages, disadvantages and complications were defined and aesthetic results of the patients were also evaluated by using a questionnaire which was filled by patients at third month after reconstruction. All flaps and grafts survived, partial or total necrosis was not encountered but one patient with ectropion had a secondary reconstructive procedure. The aesthetic results of the patients were also satisfactory. The paranasal flap is very reliable and safe method for total lower eyelid reconstruction.