Lateral Sacral Artery Perforator Flap as a New Option in Myelomeningocele Reconstruction.

BACKGROUND: This study aims to present lateral sacral artery perforator (LSAP) flaps as a new option for myelomeningocele reconstruction and to discuss their advantages and disadvantages. METHODS: Eleven patients were included in the study, and reconstruction was performed with 22 LSAP flaps. Patients were evaluated in age, gender, birth weight, kyphosis status, defect localization and size, flap size, operation time, amount of bleeding, and postoperative complications. RESULTS: Sixteen flaps were raised from the first and 6 from the second LSA. The average time for soft tissue reconstruction was 57 minutes. The mean blood loss was 11.1 mL/kg. No cerebrospinal fluid leakage was detected in any patient. In 1 of the 22 flaps, venous congestion did not completely resolved and resulted in partial necrosis secondary to venous insufficiency. In 2 patients, minimal wound dehiscence was detected in the distal part of the flap. No wound infections, hematomas, donor site complications, or seromas were observed in any patient. CONCLUSIONS: Considering that myelomeningoceles are often located in the lumbar region, we think that LSAP flaps will be a new option among other flaps. Additionally, if other flaps are used in the neonatal period, it may be a good alternative for pressure sore reconstruction in the kyphotic area.

Effect of Reduction Mammoplasty on Insulin and Lipid Metabolism in the Postoperative Third month: Compensatory Hip Enlargement.

BACKGROUNDS: The positive effects of reduction mammoplasty on metabolic profile have been shown in a limited number of studies. This study objective to reveal the effects of reduction mammoplasty on metabolic profile and anthropometric measurements. SUBJECTS AND METHOD: The study was prospectively conducted on 42 patients who were operated between April 2019 and March 2020. Fasting plasma glucose, fasting plasma insulin, total cholesterol, triglyceride, high-density lipoprotein and low-density lipoprotein cholesterol, HgA1c, homeostasis model assessment scores, adiponectin, leptin, and resistin levels were evaluated. In addition, age, height, weight, body mass index; breast, chest, waist, hip circumference; waist-hip ratio, and bilateral breast resection tissue weights were recorded. Data and blood samples were collected one hour before the operation, 6 and 12 weeks after the operation. RESULT: The patients' mean age was 43.14±10.24, and their average height was 159.42±4.96 cm. The excised bilateral dermo fatty tissue weight was 1435.85±721.16 g. At the postoperative 40th day a decrease in leptin (p = 0.001), resistin (p =0.008), glucose (p = 0.021) and insulin resistance values (p=0.013) stated. There was an increase in adiponectin (p < 0.001) and HDL (p = 0.013) levels at the postoperative 40th day. In the postoperative third month, these data returned to the previous levels that were measured before operations. However, an increase in hip circumference (p = 0.034) and a decrease in waist-hip ratio (p < 0.001) was detected in third month. Also, there was no difference in body mass index and weight compared to pre-operation. CONCLUSION: After reduction mammoplasty, compensatory fat growth in the hip area, an increase in the hip circumference, and a decrease in the waist-hip ratio were observed in the postoperative third month. LEVEL OF EVIDENCE: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Perivascular Injections of Botulinum Toxin Type A Versus Low Concentration of Ethanol.

BACKGROUND: This study aimed to investigate the effect of low concentration ethanol in increasing flap viability by perioperative perivascular application and compared it with that of botulinum toxin type A (BTX-A). MATERIALS AND METHODS: Twenty-seven Wistar albino rats weighing 300-350 g were used in this study. The subjects were randomly divided into three equal groups: group E (ethanol, n = 9), group B (BTX-A, n = 9), and group S (saline, n = 9). In rats, the dorsal multi-territory perforator flap was elevated, and the agents were injected. In postoperative 1 wk, flap viability and vascular endothelial growth factor levels were evaluated. Also, blood flow, microvascular density, and inflammation degree of both choke zones were assessed. RESULTS: The mean flap survival area and vascular endothelial growth factor level were significantly higher in group E than in group B and S (P < 0.001). Similarly, blood flow (first choke zone, P < 0.012, and second choke zone, P < 0.001) and microvascular density (first choke zone and second choke zone, P < 0.001) were found to be higher in Group E compared to Group B and S in the evaluation performed from both choke zones. Also, significant inflammation was detected in the ethanol group. CONCLUSIONS: The positive effects of BTX-A on flap viability were achieved with a low concentration of ethanol. The fact that a low concentration of ethanol increases blood flow, angiogenesis, and flap viability more than BTX-A in the first postoperative week indicates that it can be an alternative agent for perioperative use.

Helical Rim Reconstruction With Chondrocutaneous Hatchet Flap-Z Plasty.

BACKGROUND: Helical rim reconstruction is relatively difficult because of the unique anatomical structure of the ear. The aesthetic and functional characteristics of the ear make such reconstruction even more important. This article presents the newly defined chondrocutaneous hatchet flap-Z plasty (HFZP) method in helical rim defects and evaluates the results. METHODS: This study retrospectively evaluates 14 patients who were operated on using the chondrocutaneous HFZP method after a tumor excision located on the helical rim. The etiologies of the patients were basal cell carcinoma (n = 7), squamous cell carcinoma (n = 2), and actinic keratosis (n = 5). All patients were operated on under local anesthesia. The patients were evaluated regarding age, sex, etiology, defect location, and aesthetic outcomes. RESULT: Five patients were female, and 9 were male. The mean age of the patients was 72.2 years. Nine tumors were localized in the upper one-third of the helical rim, and 5 were localized in the middle one-third. The average duration of operation was 24 minutes. The aesthetic results were 11 patients (78.59%) who recovered with excellent outcome, 2 patients (14.2%) with good outcome, and 1 patient(7.1%) with poor outcome. There were no postoperative complications, such as flap necrosis, infection, suture detachment hemorrhage, or hematoma. CONCLUSIONS: The chondrocutaneous HFZP method is a simple, single-stage method that uses local tissues without color mismatch. In addition to the method's geometric gain, there is no removal of healthy skin or cartilage, resulting in minimal decreases in the vertical and horizontal diameters of the ear.

Repair of Sacral and Ischial Region Defects With Lateral Sacral Artery Perforator Flaps.

BACKGROUND: Reconstructive choices for the defects of the sacral and ischial regions include various steps of the reconstructive ladder from primary closure to free flaps. This study aimed to present repair of sacral and ischial region defects with lateral sacral artery perforator (LSAP) flaps. METHODS: We enrolled a total of 18 patients with sacral and ischial region defects reconstructed with LSAP flaps in the study between September 2014 and October 2015. The patients were evaluated in terms of age, sex, neurological situation, etiology, defect size, defect region, flap size, perforator number, and postoperative complications. RESULTS: No patient had hematoma, seroma, and complications of the donor area. In the postoperative period, 2 patients were observed to have short-term complications (11.1%) including a partial flap loss (5.5%) due to distal venous failure (flap survival rate, 95%) and a wound site infection (5.5%). Duration of follow-up of the patients ranged between 26 and 38 months. Recurrence was observed from long-term complications of 4 patients' pressure sores (22%). CONCLUSIONS: The LSAP flap has not been frequently described in the literature. We believe that LSAP flap is a flap of choice that should be considered preferably for sacral and ischial defects, which can be reliably elevated over pedicles and has short surgery duration and low surgical morbidity.

Oncoplastic and Reconstructive Breast Surgery: A Comprehensive Review.

Most of the approaches that were valid until recently in breast cancer surgery have undergone significant changes with rising awareness, increasing number of patients, and knowledge. It is important to repair the damage caused by surgical treatment performed in accordance with oncological principles and to obtain good cosmetic results. The quality-of-life indexes increase and body image is positively affected by the development of oncoplastic surgery and reconstruction techniques. The oncoplastic techniques are commonly used for the closure of glandular defects. Surgeons must pay attention to the breast volume, tumor location, the amount of breast tissue that would be removed, and the oncoplastic technique that may be required. Oncoplastic breast surgery allows wide local excision of the mass with good cosmetic results. In addition, a contralateral breast lift, breast augmentation or breast reduction may be required to accommodate the conceptually reconstructed breast. The use of oncoplastic breast surgery techniques results in lower mastectomy rates with equivalent local and long-term survival rates as compared with mastectomy and offers women the option of plastic and reconstructive interventions performed at the time of initial surgery. Mastectomy may be needed for large tumors, as breast-conserving surgery may not be possible or may not produce satisfactory cosmetic results. Breast reconstruction methods after mastectomy include autologous or implant-based breast reconstructions, which can be performed at the same time as the breast cancer surgery (immediate reconstruction) or at a later time (delayed reconstruction). Oncoplastic and reconstructive breast surgery minimizes the impact of breast cancer surgery and yields equivalent survival outcomes without psychological morbidity. With advanced techniques, better breast image than before can also be achieved. In this review, the technical details of oncoplastic breast surgery, surgical margin positivity management, reconstruction methods, radiation therapy given after reconstruction surgery, radiologic imaging modalities, and management of complications are discussed.

A Novel Basic Training Laboratory Model on Live Subjects for Supermicrosurgery: Mouse Femoral Artery, Vein and Nerve.

BACKGROUND: Increasing success rates of supermicrosurgery operations have increased the importance of developing the ideal training model for super-microsurgery. Working on the model is very important for increasing and continuing microsurgery and supermicrosurgery skills. We aimed to present a standardized, simple and easy to access live training model for supermicrosurgery. METHODS: The experiment was performed in the University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, IDEA, Istanbul, Turkey in 2020. Twelve BALB/c male albino mice weighing 20-45 gr were used in the study. Unilateral femoral artery, vein and nerve diameters of mice were measured. Anastomosis was performed on the bilateral femoral vessels. The surgical procedure times were also recorded. RESULTS: The mean weight of the mice was 36.6 ± 6.09 gr, the length was 15.10 ± 1.10 cm. The mean external diameter of the femoral artery, vein and nerves were 0.31 ± 0.34 mm, 0.48 ± 0.70 mm, 0.38 ± 0.43 mm, respectively. The mean preparation time of neurovascular structures for anastomosis was 15.75 ± 1.54 min, mean femoral artery and vein anastomosis time was 24.91±1.72 and 33.16±1.74 min, respectively. Vascular patency was detected as 100% after all vascular anastomosis procedures. CONCLUSION: Mice femoral neurovascular structures are similar to rats in terms of basic morphology, and they are small enough for super-microsurgery education model. Dissection of mice femoral bundles are easy to perform. In terms of training models, anesthetic requirement and laboratory costs are less for mice, and handling them is much easier compared to rats; thus, making them especially suitable for basic supermicrosurgery training courses.

The Effect of Very Low Concentrations of Ethanol on Microvascular Artery and Vein Anastomosis: An Experimental Study.

OBJECTIVES: This study investigated the effect of very low concentrations of ethanol on artery and vein anastomosis. Also, it was aimed to determine the appropriate ethanol concentration to be used in vasospasm. METHODS: Rats were divided into five groups of eight rats, each group, as follows: Group i: saline; Group ii: 2.5% ethanol; Group iii: 5% ethanol; Group IV: 7.5% ethanol; and Group V: 10% ethanol. During the femoral artery and vein anastomosis, 1ml of the agent was used for irrigation in each group. Vessel diameters were measured before the anastomosis, at the fifth and 15th minutes, and the third week after the anastomosis. Histopathological samples were taken in the third week. RESULTS: In Groups ii and iii, the mean vessel diameters were found to increase 15th minute. Also observed was an increase in mean vessel diameter that continued in the third week. Although acute vasodilation was detected in Groups IV and V, arterial and venous thrombosis was observed in the third week. Intima and media thickness decreased in Group ii, while it increased in Group iii. Perivascular inflammation and fibrosis increased as the ethanol concentration increased. CONCLUSION: 2.5% ethanol causes acute and prolonged vasodilation and does not cause endothelial cell damage, perivascular inflammation, and fibrosis. 2.5% ethanol will be a powerful alternative use in many situations that occur with vasospasm.

Evaluation of the serum magnesium and vitamin D levels and the risk of anxiety in primary hyperhidrosis.

BACKGROUND: Excessive sweating is considered primary hyperhidrosis if it is triggered by emotional states without any thermogenic or other underlying disease from the eccrine glands. This may be due to dysfunction in the autonomic nervous system. AIMS: To investigate the relationship between Vitamin D and Mg deficiency and the risk of anxiety and depression in patients with primary hyperhidrosis. PATIENTS/METHODS: This cross-sectional, case-control study was conducted between July and October 2019. 49 primary hyperhidrosis patients in Group I and 47 age and gender matched healthy individuals in Group II were included in the study. RESULTS: The mean 25 (OH) D and Mg levels in Group I were statistically significantly lower than in Group II (p < 0.001 and p = 0.002, respectively). Statistically significant differences were found between the groups in terms of anxiety and depression (p < 0.001 and p = 0.033, respectively). There was no significant relationship between the HADS-A / HADS-D scores and the severity of primary hyperhidrosis (r = -0.131, p = 0.096; correlation coefficient = 0.232, p = 0.447). However, a significant correlation was observed between HADS-A scores and serum Mg levels (r = -0.439, p = 0.007). CONCLUSION: Anxiety and depression are common in patients with primary hyperhidrosis. As shown in this study, both anxiety and depression can be seen with low Mg levels in patients with primary hyperhidrosis. This could possibly be related to the pathological mechanism involving Vitamin D and Mg, which determines the common pathway affecting primary hyperhidrosis and anxiety/depression.

Discussion of Histopathological Findings of 954 Breast Reduction Specimens.

OBJECTIVES: Breast reduction is a frequently sought procedure by patients and one of the most commonly performed operations by plastic surgeons. Follow-up of histopathological results after reduction mammoplasty is very important. This study aimed to evaluate the histopathological results of patients undergoing bilateral reduction mammoplasty to determine the incidence of breast lesions and risk factors of high-risk breast lesions. METHODS: 477 patients who underwent reduction mammoplasty in the plastic surgery department between October 2013 and January 2020 were included in this study. Patients were evaluated according to age, body mass index (BMI), comorbidity factors, tobacco use, family history and histopathological findings. RESULTS: The mean age of patients was 42.43±12.05 years. Body mass index ranged from 23 to 34.6. As for comorbidity factors, 12 patients had hypertension, five patients had asthma and six patients had diabetes mellitus. Seventeen patients (3.6%) were smokers, and 25 (5.2%) patients had a family history of breast cancer. Among the patients, 2.3% were 20 years and under, 17.1% were between 21 and 30 years old, 21.5% were between 31 and 40 years old, 33.1% were between 41 and 50 years old, 18.2% were between 51 and 60 years old, and 7.5% were 60 years and above. 85.4% of histopathological findings consisted of normal breast tissue and nonproliferative breast lesion breast lesions. The incidences of proliferative breast lesions, atypical hyperplasia and in situ lesions were calculated as 5.7%, 2% and 0.4%, respectively. The mean follow-up period was 3.8±1.6 years. CONCLUSION: Although preoperative breast cancer screening methods are used before the reduction mammoplasty, high-risk lesions may be encountered afterwards. One of the biggest advantages of reduction mammoplasty in addition to psychophysiological recovery is breast cancer risk reduction.

Reconstruction of Complex Scalp Defects in Different Locations: Suggestions for Puzzle.

OBJECTIVE: Scalp defects may occur following trauma, radiotherapy, oncologic resection, and recurrent surgeries. The hair-bearing scalp has a dual role, which consists of protecting the calvarium and contributing to aesthetic appearance. While the "reconstructive ladder" approach may be used to close small and medium-sized scalp defects, it is not the case for larger ones involving the calvarium or with a radiation therapy history. The aim of this study is to present cases operated due to complex scalp defects, analyze complications, and discuss the choice of reconstruction. MATERIAL AND METHODS: The study consists of 14 patients who were operated between December 2017 and August 2019 due to a complex scalp defect. Patient were evaluated according to age, gender, etiology, radiation therapy history, defect size and location, reconstruction steps, cranioplasty and duraplasty options, type of free flap, recipient artery, vein graft requirement, and complications. RESULTS: The mean age of patients, which consists of 11 men and three women, was 56.7 years. The etiology for scalp defects included basosquamous carcinoma, squamous cell carcinoma, giant basal cell carcinoma, atypical meningioma, glioblastoma multiforme, angiosarcoma, and anaplastic oligodendroglioma. The defect involved the full thickness of calvarium in nine cases and pericranium in five cases. Cranioplasties were made with rib graft (n=1), bone graft (n=1), and titanium mesh (n=7). Free flaps used for reconstruction were musculocutaneous latissimus dorsi (LD) (n=4), LD muscle (n=3), anterolateral thigh (ALT) (n=4), musculocutaneous ALT (n=1), vastus lateralis muscle (1), and rectus abdominis muscle (n=1). Flap loss was not observed. Complications occurred in four of the patients; include a partial graft loss, a wound dehiscence, seroma, and an unsatisfactory esthetic result. CONCLUSION: Free tissue transfers rather than local flaps should be opted to reconstruct complex scalp defects, as failure of the latter, could create much greater defects, and worse consequences. There are many options for proper reconstruction, and it is essential to select the appropriate one, taking into account the comorbid conditions of each case.

Effect of perivascular low dose ethanol on rat femoral vessels: Preliminary study.

Vasospasm is one of the important causes of morbidity in free flap and replantation surgery. In secondary Raynaud's phenomenon, nearly half of the patients experience digital ulceration, pain and loss of function at least once in their lifetime. The aim of this study is to investigate the vasodilation effect of ethanol-mediated chemical denervation on peripheral vessels by topical administration. In this study, 27 Wistar albino male rats weighing 250-300 grams were used. The rats were randomly divided into three groups: saline (group S, n = 8), lidocaine (group L, n = 9) and 96% ethanol (group E, n = 9). According to group, 0.1 mL saline, 0.1 mL lidocaine and 0.1 mL ethanol were applied around the rat femoral neurovascular bundle. After the application, on the 0th day and 3th weeks, femoral artery and vein diameters were measured. After 3. weeks, histopathological samples from femoral artery, vein and nerve were evaluated. On the 0th day, the mean diameter of the femoral artery and vein was similar in group E and L and higher than group S. After three weeks, the vasodilatation effect of ethanol was increased in group E. In Group L and S, the vasodilatation effect was lost. Histopathological examination showed that ethanol significantly caused perivascular inflammation and nerve degeneration compared to other agents and did not cause endothelial damage. Vasodilatation obtained by ethanol is a rapid onset and long-lasting effect. It is also inexpensive and effective for peripheral vasodilatation.

Congenital lateral cleft palate with unilateral craniofacial microsomia and lateral ankyloglossia.

Craniofacial microsomia is a group of anomalies that occur due to developmental defects in the first and second branchial arches during the embryological period. The disease has various craniofacial and extracraniofacial presentation patterns. Lateral cleft palate is distinct from the most common palate clefts because it is located lateral to the uvula. The presence of a lateral cleft palate has been very rarely reported in the literature, and the aetiopathogenesis of the disease is still not well understood. We aimed to report a case of the coexistence of lateral cleft palate and craniofacial microsomia and discuss the aetiopathogenesis of these diseases.

Management and Treatment of Pressure Ulcers: Clinical Experience.

OBJECTIVES: Pressure ulcers are a common healthcare problem, particularly among hospitalized patients who need long-term treatment; however, preventive medicine can reduce the prevalence. A multidisciplinary approach is fundamental to providing proper care, and the general health status and cooperation of the patient determine treatment modalities. Simple methods can prevent pressure ulcers and their recurrence. The aim of this study was to share clinical experience and evaluate the approach and treatment modalities used for pressure ulcers. METHODS: Fifty-two patients hospitalized with the indication of pressure ulcers were evaluated retrospectively. Age, sex, localization of the decubitus ulcer, treatment method, comorbid diseases, and any postoperative complications were analyzed. RESULTS: Thirty-five patients were male and 17 were female. The mean age was 50.3 years. The most common accompanying disease was diabetes mellitus and the most common etiology was paraplegia. Pressure ulcers were localized on the sacral area in 45 patients, the ischial area in 23, the trochanteric area in 11 patients, and other parts of the body (scapular, lumbar) in 3 patients. Fasciocutaneous rotation flaps, myocutaneous flaps, and perforator flaps were the most used reconstruction techniques. No major complication was observed. CONCLUSION: The most important point with regard to pressure ulcers is prevention. Healthcare system expenses can be significantly reduced by preventing the formation of decubitus ulcers. The progression of pressure ulcers can be easily controlled if the necessary care and treatment are provided in the early period. The role of the plastic surgeon in advanced stages is to perform reconstruction in appropriate cases and to educate patients and their caregivers with the aim of preventing recurrence.

Use of dorsal intercostal artery perforator flap in the repair of back defects.

BACKGROUND: The dorsal intercostal artery perforator (DICAP) flap is a well-vascularised flap that is elevated above the dorsal branch of the vertebral segments of the posterior intercostal artery. The aim of this study was to repair back defects using DICAP flaps. MATERIALS AND METHODS: Eight patients who had undergone reconstruction with DICAP flaps for defects located on the back of the torso due to conditions of various aetiologies between 2011-2014 were included in this study. Patient age and gender, aetiology of the condition, dimensions of the defect and the flap, site of the defect, and postoperative complications were recorded. RESULTS: Three females and five males were included in this study. The age of the patients ranged between 19-71 years (mean = 53.6 years). The aetiology was skin tumour in five patients and pressure wound, gunshot injury, and plate screw exposition subsequent to spinal surgery in one patient each. The sites of the defects were successfully closed in all patients, and no flap loss was observed in any patient. CONCLUSIONS: DICAP flaps have some advantages compared to conventional muscle and muscle skin flaps, such as greater protection of muscle functions, less invasiveness, and lower donor site morbidity. This flap has a high mobilisation capacity due to its elevation above nine bilateral perforator arteries. Therefore, the DICAP flap is useful for the repair of median and paramedian back defects. Based on its advantages, it is suggested that the DICAP flap should be considered as a useful option for the repair of back defects.

Retromandibular transparotid approach to mandibular subcondylar and high ramus fractures: two-point fixation.

BACKGROUND: Although the fractures of the mandibular condylar region are very common, the controversies about the treatment of this area is still ongoing. In recent years, general agreement has emerged that open treatment is more effective than closed approaches for extracapsular condylar fractures. However, this time, the method of surgical approach has become controversial. The aim of this study was to evaluate the effectiveness of the retromandibular transparotid approach for the fixation of subcondylar/high ramus mandible fractures. METHODS: Subcondylar/high ramus mandible fractures were operated via the retromandibular transparotid approach with a two-point fixation in 24 patients. The patients were evaluated for bleeding during the operation and for hematoma, infection, Frey's syndrome, salivary fistula, facial nerve damage, occlusion, fracture site stability, chronic pain in the fracture site, hypoesthesia of the ear, and temporomandibular (TME) joint movements in the postoperative period. RESULTS: Only one major complication was encountered in one (4.1%) patient, which was damage to the temporal branch of the facial nerve. CONCLUSION: The retromandibular transparotid approach appears to be a safe and effective method for the internal fixation of extracapsular condylar fractures.