Venous super-drained posterior interosseous artery flap for dorsal hand defects.

BACKGROUND: Posterior interosseous artery flap PIAF is one of the most preferred reconstructive options for upper extremity defects. As a reverse flap, venous congestion is always a threatening factor. In this report authors aimed to present their experience with venous super-drained posterior interosseous artery flap VS-PIAF. METHODS: Between January 2013 to September 17, 2017 patients were treated with VS-PIAF. Tumor excision, trauma, traffic accident, burn contracture release, and industrial injuries were the causes of defects. Defects were located on the dorsum of the hand, first web space, ulnar and radial side of the hand, and the palm. All the defects were reconstructed with a VS-PIAF, which a distal superficial end-to-end venous anastomosis was added to overcome venous congestion problems. RESULTS: The flap sizes were between 5 × 7 cm and 8 × 12 cm. All the flaps have survived completely without any early or late complications. No venous problems were seen. The donor areas were healed uneventfully. The mean follow-up time was 15.3 months. The results of reconstructions were satisfactory, no functional restrictions was seen. CONCLUSION: The major drawback of PIAF is venous congestion problems that can be manageable with adding a distal superficial end-to-end venous anastomose. VS-PIAF is a robust, much safer and easy-to-learn reconstructive method for upper extremity defects.

Variance of melatonin and cortisol rhythm in patients with allergic rhinitis.

OBJECTIVE: Allergic rhinitis is an IgE-mediated inflammatory disease which effects 10%-50% of the normal population. The mechanism of its formation and the circadian rhythm of cortisol and melatonin in allergic rhinitis have not been investigated. STUDY DESIGN: Salivary levels of melatonin and cortisol were measured by radioimmunoassay in 35 newly diagnosed allergic rhinitis patients and in 23 control subjects matched for age and gender. RESULTS: In the study group; amplitude, baseline and peak levels of salivary melatonin were significantly decreased compared with healty controls (p<0.001). No differences were found in the acrophase and the peak duration of salivary melatonin between the study and control groups (p>0.05). In the study subjects, the circadian rhythm of cortisol was flattened when compared with the control group. The amplitude and the 24h mean levels of salivary cortisol in the study group were significantly lower than in the control group and the acrophase was delayed in patients compared with control subjects (p<0.001). CONCLUSION: The circadian rhythms of salivary melatonin and cortisol were found to be disrupted in patients with allergic rhinitis. These results may also be contributive data to explain the pathogenesis of allergic rhinitis and also they can be applicable as adjunctive therapeutic tools in the future and melatonin drugs might be an alternative in the therapy of resistant allergic rhinitis patients or allergic rhinitis patients who cannot use cortisol drugs.

The effect of reduction mammaplasty on the vertebral column: a radiologic study.

Some studies emphasized that anatomic mechanisms of vertebral aberrations could be associated with large breasts. The effect of mammaplasty operation on the vertebral column and body posture seems to be beneficial; in this trial, it was planned to investigate the objective radiologic effect of reduction mammaplasty on the posture of the vertebral column in a group of patients operated due to the large breasts. Thirty-four white women with large breasts were enrolled in this study. The patients were divided into three groups according to their breast cup sizes. Anteroposterior and lateral radiographs of the lumbosacral and thoracic spine were taken at baseline preoperatively, and the same radiographic images were taken in an average of 12 months later than the reduction mammaplasty operation. All were evaluated and compared for thoracic kyphosis angle and lumbar lordosis angle both preoperatively and postoperatively. The mean thoracic kyphosis angle was 40,53 preoperatively and 39,38 postoperatively. However, there was no statistically significant difference between the preoperative and postoperative measurements in all groups (P > 0,05). The mean lumbar lordosis angle was 54,71 preoperatively and 53,18 postoperatively. Regarding the preoperative and postoperative measurements of lumbar lordosis angles, no statistically significant difference was found between the groups (P > 0,05). Although breast size may be an important factor that affects body posture, reduction mammaplasty operations have little or no radiologic effect on the vertebral column.

Splitted posterior auricular muscle flap combined with traditional otoplasty.

OBJECTIVE: This article presents a modified technique to split and reposition the posterior auricular muscle flap as an adjunct to traditional otoplasty. BACKGROUND: Although numerous techniques have been described for the correction of prominent ear deformity, there is still a continuing debate on which operative method achieves the best results. Recurrence of the deformity or the need for secondary revisions is still among the common problems. We aimed to focus on a technical modification of the use of the postauricular muscle flap to strengthen the effect of otoplasty and to obtain more prominent results. METHODS: Twelve patients with prominent ears (total, 24 ears) were operated on and followed up at least 6 months. To determine the efficacy of the technique on the different parts of the ears, 2 distances of each ear to the scalp for both the superior and middle third of the ears were measured and compared before the surgery, early after the surgery, and late after the surgery. RESULTS: The mean distances for both the upper and middle third of the ears were significantly lower (P < 0.05) at the end of the first month after the surgery. Although a millimetric slight rise was observed, there was no statistically significant difference between the mean postoperative results of the first and sixth months (P > 0.05). CONCLUSIONS: The splitted posterior auricular muscle flap repositioning to the upper and middle third of the ear may be successfully performed adjunct to the conventional corrective otoplasty. According to the late postoperative results, it seems to be that a stronger and more permanent otoplasty may be obtained with the addition of a splitted and reinserted postauricular muscle flap to the traditional otoplasty.

Enhancement of venous drainage with vein stripper for reversed pedicled neurocutaneous flaps.

The flaps based on the vascular axis of superficial sensitive cutaneous nerves had gained increased popularity in reconstructive surgery because of such major advantages as preservation of major extremity arteries and avoidance of microsurgical procedures. However, postoperative venous congestion resulting in partial or total necrosis is still a common problem for these flaps. The aim of the current study is to introduce a new method for reducing the postoperative venous congestion of neural island flap with the results of reconstruction of the soft tissue defects of foot and ankle. This method was used to treat 19 patients with various chronic soft tissue defects of the foot and ankle between 2011 and 2012. We observed that the novel method presented in this report enables effective venous drainage, solving the postoperative venous congestion problem of these flaps.

Monitorization of asymmetric dimethylarginine (ADMA) levels in an experimental ischemia-reperfusion flap model: a preliminary report.

One of the most important endothelium-derived vasoactive mediators is nitric oxide (NO). Endothelial dysfunction by the loss of NO is a critical event during ischemia. Asymmetric dimethylarginine (ADMA) is a competitive inhibitor of NO synthase (NOS) that inhibits vascular endothelial NO production in concentrations found in pathophysiological conditions. The goal of this study was to monitorize overexpression of ADMA in an experimental ischemia-reperfusion flap model. This study was performed using 20 rats. The baseline ADMA levels were measured preoperatively. In Group I (n = 10, control) abdominal flaps were harvested and replaced in situ without creating ischemia. The plasma ADMA levels were measured at 1, 12, and 24 hours postoperatively. In Group II (n = 10, study) abdominal flaps were harvested, and clamping the vascular pedicle created a subsequent 8-hour period of warm ischemia. Clamps were removed and provided tissue reperfusion. The ADMA levels were taken after 1 hour of reperfusion, and at 12th and 24th hours. The mean preoperative ADMA levels in group I and group II were calculated to be 0.37 ± 0.06 (µmol/L) and 0.40 ± 0.06 (µmol/L), respectively. The differences between the preoperative ADMA levels were not statistically significant (p > 0.05). The mean postoperative ADMA levels in group I (control) were calculated to be 0.39 ± 0.09 (µmol/L) at the first hour, 0.42 ± 0.07 (µmol/L) at the 12th hour, and 0.40 ± 0.08 (µmol/L) at the 24th hour. Respectively, the mean postoperative ADMA levels in group II were calculated to be 0.68 ± 0.14 (µmol/L) after 1 hour of reperfusion, 0.62 ± 0.09 (µmol/L) at the 12th hour, and 0.60 ± 0.12 (µmol/L) at the 24th hour. All postoperative ADMA levels were significantly higher in Group II (p < 0.05). These experimental results suggest that systemic production of ADMA is greater in animals having ischemia reperfusion injury of the skin flaps. The strategy of decreasing levels of ADMA may be beneficial to prevent ischemia-reperfusion injury of flaps or composite transplants; thus, ADMA might be an important candidate of therapeutic target in flap or transplantation surgeries.

Airbag cover impact: a rarely seen reason for mandibular defects.

Airbags and seatbelts are among the primary means of preventing severe injuries after motor vehicle accidents. Nonetheless, many studies have examined injuries that were related to airbag deployment. To our knowledge, this is the first case report of multiple mandible fractures caused by impact with the airbag cover. Removal of non-viable bone fragments was performed and the resulting hemi-mandible defect was reconstructed with a free iliac crest flap. A radial forearm free flap was used to reconstruct the mucosal defect. Airbags can prevent deadly injuries; however, they can also cause serious harm to the maxillofacial bones at the time of deployment.

The Role of CD34 and D2-40 in the Differentiation of Dermatofibroma and Dermatofibrosarcoma Protuberans.

OBJECTIVE: Dermatofibroma (DF) is a benign fibrohistiocytic tumor whereas dermatofibrosarcoma protuberans (DFSP) has intermediate malignant potential. CD34 is the most commonly used antibody in differentiating these tumors. Various studies have stated the rates of D2-40 expression as 0-50% in DFSPs and 86-100% in DFs. Our aim in this study was to determine the expression of CD34 and D2-40 in DFs and DFSPs and the possible use of D2-40 in the differential diagnosis of these lesions. MATERIAL AND METHOD: This is a retrospective study including 30 DF and 15 DFSP cases which were reevaluated for epidermal changes, the presence of a transmission zone (Grenz zone), infiltration of soft tissues, infiltration pattern and histologic subtypes in addition to cellular pleomorphism, nuclear atypia, and necrosis. A manual immunohistochemistry procedure was performed with D2-40 and CD 34 antibodies using a representative paraffin block. RESULTS: The average age was 37.36 and 42.86 years in the DF and DFSP cases. The average diameter was 0.9 and 5.03 cm, respectively, for the DFs and DFSPs. There was a significant correlation between the two entities for sex, localization and diameter of the lesion. A significant difference was found between the positivity of CD34 and D2-40 in DFs and DFSPs. CONCLUSION: Additional immunohistochemical markers may be needed in DFs with CD34 positivity. Our results showed the additional helpful role of this marker in problematic cases.

Basal cell carcinoma in Turkey.

Basal cell carcinoma (BCC) is the most common form of cancer in Caucasians. This study was undertaken to define clinical features of BCC treated by surgical excision in Turkish patients. One-hundred and ninety-eight patients with 216 BCC, all treated by surgical excision, were studied prospectively. Age and sex distribution, personal and family history, skin type, site and size of the lesions, clinical type of the lesions, status of surgical margins and incidence of recurrence were analyzed. The male to female ratio was 9:10, and the average age of the patients was 64.5 years. Of the tumors, 91.5% occurred on the head and neck. There was also personal and/or family history of cancer in 24.8% of our cases. Of all BCC treated, 83.8% had a noduloulcerative clinical appearance. The vast majority of our patients were Fitzpatrick type 3 (53.0%) and type 2 (41.5%). There were seven recurrences after follow-up periods varying between 3 months and 2 years. In conclusion, clinical characteristics of BCC in Turkish patients have both similarities and differences compared with other countries.

Basal cell carcinoma in Turkey.

Basal cell carcinoma (BCC) is the most common form of cancer in Caucasians. This study was undertaken to define the clinical features of BCC treated by surgical excision in Turkish patients. A group of 198 patients with 216 BCCs, all treated by surgical excision, were studied prospectively. The age and sex distribution, personal and family histories of the patients, skin type, sites and sizes of the lesions, clinical types of the lesions, status of the surgical margins, and incidences of recurrence were analyzed. The male to female ratio was 0.9, and the average age of the patients was 64.5 years. Of the tumors, 91.5% occurred on the head and neck. There were also personal and/or family histories of cancer in 24.8% of our cases. Of all BCCs treated, 83.8% had a noduloulcerative clinical appearance. The vast majority of our patients were Fitzpatrick type 3 (53.0%) and type 2 (41.5%). There were seven recurrences after follow-up periods varying between three months and two years. In conclusion, the clinical characteristics of BCC in Turkish patients have both similarities and differences compared to those of other countries.

Effect of sildenafil citrate on viability of flaps: an experimental study in rats.

Various pharmacological agents have been used to try and elucidate the pathophysiology of ischaemia and necrosis of flaps. Their most important disadvantage is the need for relatively high doses given systemically, which increases the risk of potential side effects. Topical or local agents are more useful. Sildenafil citrate, the specific inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE 5) was studied as an antianginal drug during the late 1980s, but is now used for its effect on erectile function in men. Sildenafil citrate causes dilatation of peripheral arteries and veins and the inhibition of the thrombus-forming ability of platelets in vivo. Our study was designed to test the efficacy of sildenafil citrate on the viability of flaps.

Alternative method for the reconstruction of meningomyelocele defects: V-Y rotation and advancement flap.

OBJECT: Skin grafts, skin flaps, fasciocutaneous flaps, muscle flaps, and musculocutaneous flaps have been used for closure of large meningomyelocele (MMC) defects that cannot be closed primarily. The V-Y rotation advancement flap technique has been used successfully for the reconstruction of defects in different areas of the body. In the present study, the authors report on their novel use of this technique in both a binary and a quadruple (butterfly) flap manner for closure of large MMC defects. They also present an algorithm that they developed for the evaluation of MMC defects. METHODS: Between January 2011 and November 2013, 17 patients (13 girls and 4 boys) with extremely large MMC defects that could not be repaired by direct primary closure underwent reconstruction of the defects with binary and quadruple V-Y rotation and advancement flaps. With the patient prone, the axillary apices, the most craniad point of the intergluteal sulcus, and the posterior axillary lines were marked, and a rectangular area on the back was designed. Edges of the rectangular area and the transverse and longitudinal diameters of the defect were measured and the presence of kyphosis was noted. These measurements and their proportions were used to develop an algorithm for patient assessment. While binary flaps were planned over the transverse diameter of the defects, quadruple flaps were planned over the bisectors of the defects, which were closed by elevating fasciocutaneous flaps. RESULTS: For patients whose defect diameter to back width ratio was between 0.30 and 0.50 and whose mean ratio of defect area to donor area was between 0.09 and 0.15, binary V-Y rotation and advancement flaps were used. When these values were in the range of 0.50-0.66 and 0.16-0.35, respectively, quadruple V-Y rotation and advancement flaps were preferred. The mean duration of postoperative follow-up was 10.4 months. With the exception of minor complications, such as partial necrosis of 0.5 × 0.5 cm in a quadruple flap, all the flaps healed uneventfully. CONCLUSIONS: With this study, closure of MMC defects with V-Y rotation and advancement flaps has been defined for the first time in the literature. The use of this technique with multiple flaps is an effective alternative to other flap options for the closure of large MMC defects. The algorithm developed in the course of this study should facilitate evaluation and reconstruction planning for patients with MMC defects.

Polydactyly: a study of four generations of a Turkish family including an affected member with bilateral cleft lip and palate.

Polydactyly is one of the most common congenital deformities of the hands. It can occur as an isolated disorder, in association with other malformations of the hands or feet, or as part of a syndrome. It can occur sporadically but it can also be inherited with a mainly autosomal dominant inheritance. We present a Turkish family with affected members in four generations. Bilateral duplication of the second digit in both hands and feet with 24 digits in total was the most common pattern, but one affected member had 26 digits: seven on each hand and six on each foot. In addition, another affected member had complete bilateral cleft lip and complete cleft palate combined with bilateral hand and foot polydactyly without any syndromic association. The pedigree of the affected members of this family suggests an autosomal dominant mode of inheritance, but genetic expression is variable.

Malignant pilomatrixoma arising on the previously irradiated face: case report and literature review.

BACKGROUND: Malignant pilomatrixoma (also known as pilomatrix carcinoma) is a very rare malignant neoplasm derived from the hair matrix. These slow-growing malignancies of the skin are found in the lower dermis and subcutaneous fat layer. They can exhibit local aggressive behavior or distant metastasis. This malignancy can arise as a solitary lesion de novo or through transformation of a pilomatrixoma over a long period. There is no known distinct etiologic factor or predisposing condition for this kind of malignancy. OBJECTIVE AND CONCLUSION: We present an interesting case of a 65-year-old man with a pilomatrix carcinoma arising on the previously irradiated face due to the malignant neoplasm of the parotid gland. This is the first report of a pilomatrix carcinoma that has developed on a region that has undergone radiotherapy for another malignancy.

Case series of topical and orally administered ß-glucan for the treatment of diabetic wounds: clinical study.

BACKGROUND: Chronic, nonhealing wounds, foot ulcers, and lower extremity amputations are among the most problematic complications associated with diabetes mellitus. Standard care for diabetes-related chronic ulcers has included treatment of infection, weight off-loading, aggressive surgical débridement, and maintenance of a moist wound environment with frequent dressing changes. OBJECTIVE: Yeast glucan is a particular high-molecular-weight polymer of ß-(1,3)-glycosidic linkages of glycopyranose. We report our observations about the effectiveness of topically and orally administrated ß-(1,3)-glucan for the treatment of chronic diabetic wounds and compare them to the literature results previously reported for similar wounds. MATERIALS AND METHODS: Twenty-two patients with nonhealing ulcers associated with diabetes were included in this study. ß-Glucan was given both orally and topically for the treatment of nonhealing ulcers. Macroscopic changes and surface areas of diabetic ulcers were recorded, and complete healing times were noted for each patient. RESULTS: A rapid decrease in size and healthy granulation were significantly observed in most patients. The duration of complete healing averaged 10.8 weeks (range 6-20 weeks). No adverse events were observed in the treatment period. The complete healing time was shorter than the results previously reported in the literature. CONCLUSIONS: Our observations support the view that application of glucan hastens epithelialization and wound closure, so topically and orally administered ß-(1,3)-glucan therapy can help reverse some of the deficits in impaired healing diseases such as diabetes mellitus.

Protective effect of grape seed extract against ischaemia/reperfusion injury in a rat epigastricflap model.

Proanthocyanidins are potent natural antioxidants which belong to a class of polyphenols. Proanthocyanidin-rich extracts are prepared from grape seeds. The effect of grape seed proanthocyanidin extract (GSPE) on the viability of abdominal skin flaps exposed to warm ischaemia and subsequent reperfusion were studied in 40 male Wistar rats. In the control group (group I; n=20), rats were fed with standard, non-purified rat diet, and the study group received GSPE 100 mgkg(-1) per day 1 week prior to surgery and 1 week following surgery. Abdominal island flaps were elevated in both the groups and subjected to 8h of warm ischaemia, followed by reperfusion. Mean flap survival areas in groups I (control group) and II (treatment group) were calculated to be 58.3%+/-11.72 and 81.0%+/-11.88, respectively. Flap survival on day 7 was significantly higher in group II compared to group I (p<0.01). Histopathological semi-quantitative analysis of the specimens revealed infiltration by polymorphonuclear leucocytes, oedema formation and necrosis in group I, whereas neo-vascularisation and fibrosis were the prominent findings in group II.

Evaluation and management of exposed high-density porous polyethylene implants: an experimental study.

Numerous autogenous and alloplastic materials have been used for restoration of contour deformities of the face. Alloplastic materials have come into use to replace autogeneous bone grafts because bone grafts are associated with donor site morbidity, resorption and difficulty in shaping. Porous high-density polyethylene (HDPPE) is a commercial product which is nonallergenic, nonantigenic, noncarcinogenic and nonresorbable, highly stable and somewhat flexible. It has pores of 125-250 mum which enable tissue ingrowth resulting in firm attachment and integration of the implant to the surrounding tissues. In this study we aimed to evaluate the fate of the exposed implants and proposed a method to manage the exposed medpor implants. Twenty rats were used for this experimental study. Three phases involving the implantation, exposition, and the closure of the implants were held respectively. Closure was performed in two groups: 1) After perforating the exposed implants; 2) Without perforating the exposed implants. No serious complications were seen. Perforated exposed implants when covered with flaps rather than grafts could be covered. Exposed implants were not covered easily as indicated by the previous studies. This study demonstrates that early closure of perforated implants with flaps can give the best clinical results when exposed implants are covered in a short period after exposition so that the ingrown fibrous tissues are still intact. We believe that grafting of the exposed medpor implants cannot be effective either in early or late period. Perforating the exposed implants yield successful results as ingrowth of the tissues are enabled.

Pull-in suture technique for the treatment of mallet finger.

BACKGROUND: Mallet finger deformity is a common disability that causes discomfort and inconvenience to the patient. Although numerous operative techniques have been described, surgical management remains controversial. METHODS: Between 2002 and 2004, 19 patients with an unsuccessful splinting regimen history, chronic deformities of tendinous origin (>3 months after the injury), or fractures involving 30 percent or more of the articular surface underwent surgical treatment. In 11 patients, chronic mallet finger deformity with tendinous origin was present, whereas eight patients presented with mallet fractures involving more than 30 percent of the articular surface. Open reduction with internal "pull-in" sutures and distal interphalangeal joint immobilization with Kirschner wire was accomplished. Active motions of the proximal interphalangeal and metacarpophalangeal joints were not restricted. After removal of the Kirschner wire at week 6, active flexion exercises were commenced immediately, and daily activities were not restricted. Full activity was allowed at day 7. Goniometric measurements, radiographs, and patient satisfaction were evaluated during the follow-up period. RESULTS: The mean follow-up period of the patients was 16 months (range, 4 to 28 months). Mean extensor lag of the distal interphalangeal joint was 2 degrees (range, 0 to 6 degrees). The mean flexion of the distal interphalangeal joint was 74 degrees (range, 60 to 90 degrees). According to Crawford's evaluation criteria, 14 excellent and five good results were obtained. Apart from radiologically documented mild degenerative changes or joint narrowing in six patients, no complication was encountered. CONCLUSION: The pull-in technique allows accurate realignment of the tendon-bone unit without any specific instrumentation or intraoperative fluoroscopic imaging methods.

Prevention of tendon adhesions by the reconstruction of the tendon sheath with solvent dehydrated bovine pericard: An experimental study.

BACKGROUND: The achievement of the kinetic functions of a finger in full range of motion after the injury and the repair of the flexor tendon has been a challenging issue in hand surgery. Several current studies emphasize the importance of the tendon sheath for the healing of the tendon and for the prevention of the adhesive bands and advise primary repair or reconstruction of them. Various biological and synthetic materials have been used for this purpose with different rates of success. METHODS: In this experimental study, the sheaths of flexor tendons of chicken toe were excised and three groups were observed: group 1, primary sheath not repaired; group 2, sheath repair with autogenous fascia; and group 3, sheath reconstruction with solvent dehydrated bovine pericardium (SDBP). RESULTS: Histopathologic evaluations were performed on the 3rd and 12th weeks to determine the outcome of the repair methods regarding the gliding surfaces of the tendons, adhesion rates, and inflammatory reactions, which are the main issues on the healing of the tendon. The results indicated less formation of adhesions in group 3 compared with groups 1 and 2 (p = 0.001). CONCLUSION: The results showed that SDBP can be used for the reconstruction of the sheaths successively for the prevention of the adhesive bands in flexor tendon surgery.

Combined use of hair and fibrin glue for soft tissue augmentation: experimental study.

A vast variety of alloplastic materials together with autogenous grafts have been used for the correction of contour deformities related to aesthetic and reconstructive purposes. Despite a number of well-tolerated materials, the ideal has not yet been reached, although well-tolerated autogenous grafts have higher rates of resorption and distortion. The limited volume of autogenous grafts and concerns about donor-site morbidity may obligate the surgeon to use implantation materials. Covering almost every property of an ideal implantation material, hair, an organic autogenous nonvital tissue, was used for soft tissue augmentation in this experimental study. Hair pellets of 10 New Zealand rabbits were prepared and shaped as 1 x 1 x 1-cm cubes with the help of fibrin sealant, then inserted subcutaneously. The materials were evaluated 4 months later. No complications such as infection or extrusion were seen. The materials were intact, with no signs of resorption, but the shapes were distorted due to the pressure of the surrounding tissues. Histopathologic findings also demonstrated that the hair was well tolerated by the adjacent tissues. Different processes may enable hair to be used as a filler material in clinical practice. Well-tolerated, nonresorbable injectable materials or shaped implants may be obtained at low cost using hair.