Hybrid reconstruction of distal nasal defects.

We present hybrid reconstruction of distal lateral "through-and-through" nasal defects (skin, cartilage, and mucosa) due to resection of tumor and/or infection. Retrospective descriptive study. The study was performed in multicenter clinics between July 2011 and September 2016. 13 patients with full thickness distal nasal defects secondary to tumor and/or infection were included. Defects included dorsal and/or caudal septum, upper lateral cartilage, or inner/outer nasal valve. Caudal-based turn-in flaps were planned and used to repair inner lining of nasal cavity. Conchal and septal cartilages were used as cartilage grafts. Skin defects were reconstructed with lateral nasal artery perforator flaps. All flaps healed uneventfully, without flap loss. Nasal passage collapse, adhesion, or difficulty in breathing were not seen. No hematoma, infection, and deformity at cartilage graft donor areas was observed. During nasal reconstruction, it is mandatory to consider 3D complex and functional structure of nose. The repair of skin defects may not be enough for functional restoration. We believe that single step reconstruction of full thickness nasal defects through hybrid reconstruction may lead to anticipated successful results.

Effectiveness of Different Surgical Flap Delay Methods and Their Systemic Toxicities.

OBJECTIVE: The surgical flap delaying has been shown to be effective in preventing partial flap loss or in preparing larger flaps. However, there is no gold standard flap delay method in the literature. In this study, the authors aimed to compare 3 types of surgical delay methods to determine which model would increase more flap survival. The authors also investigated the effect of delay methods on circulating mononuclear leukocytes as a parameter of DNA damage. METHODS: Twenty-four Sprague-Dawley male rats were divided into 4 groups. All subjects had a 10 × 3 cm modified McFarlane flap. Surface area measurements, biopsies, and blood samples were taken on the day of sacrification; 7th day for the control group and 14th day for delay groups. RESULTS: Between incisional surgery delay groups, a significant difference was found in necrosis and apoptosis in the bipedicled group, and only necrosis in the tripedicled group compared to the control. In terms of DNA damage, it was found higher in all experimental groups than in the control group. CONCLUSIONS: Both incisional surgical delay procedures' results were meaningfully effective when only incisions were made without the elevation of flaps. In conclusion, bipedicled incisional surgical delay seems to be the most effective method in McFarlane experimental flap model whereas two-staged surgeries may increase the risk of systemic toxicity.

Facial Artery Perforator and Depressor Anguli Oris Muscle Chimeric Flap: A New Design of an Old Flap.

BACKGROUND: The aim of this study was to investigate the reliability and outcomes of the facial artery perforator and separately elevated depressor anguli oris (DAO) muscle chimeric flap for the reconstruction of partial or total lower lip defects. METHODS: Eleven patients with malignant skin tumors located at the lower lip were operated between 2013 and 2015. After the excision of the tumor with adequate clear margins using margin controlled excision technique, an appropriate flap fitting to the resultant defect based on the perforators of the facial artery and DAO muscle was prepared and placed into the defect. The DAO muscle activity was tested with electromyography in the postoperative first year examination. RESULTS: Besides 1 patient with transient venous insufficiency, all the flaps healed well without a partial or total flap loss. The mean follow-up period was 10 months. No new primary tumor or recurrence was observed. Although in 1 patient, transient asymmetric smiling and mild drooling was observed, the overall oral competence results were found to be quite satisfactory. The electromyography evaluation of DAO muscle of 5 patients who reached the postoperative first year examination showed action potential results in normal limits with a slight decrease. All patients were satisfied with the final esthetic and functional result. CONCLUSIONS: The facial artery perforator and depressor angel oris muscle chimeric flap is a valuable option for reconstruction of lower lip defects providing esthetically and functionally good results.

Flexor Tenosynovitis Due to Tuberculosis in Hand and Wrist: Is Tenosynovectomy Imperative?

The treatment of flexor tenosynovitis in the hand and wrist due to tuberculosis is controversial. Although some authors recommend the antituberculous chemotherapy, the others recommend the surgical treatment. In this article, 12 patients with synovial tuberculosis of the flexor aspect of the hand and the wrist were evaluated with respect to diagnosis and treatment modalities. None of the patients had a history of tuberculosis, concomitant disease, immunosuppressive drug use, drug abuse, and human immunodefficiency virus positivity. A chest x-ray and family screening were performed in all of the cases, none had evidence of tuberculosis in the lung. The biopsy, histopathological examination, acid-fast bacillus staining, and BACTEC tuberculosis culture were performed. Antituberculous chemotherapy was initiated in patients diagnosed with tuberculosis by either histological or microbiological examinations. The patients did not undergo any further surgery after biopsy procedures. The lesions regressed totally in all patients after 3 months of treatment. Carpal tunnel syndrome symptoms and signs recruited at five months of treatment. In patients with flexor tuberculosis tenosynovitis, it is possible to achieve good results by applying only medical therapy after a biopsy, and without the need for further surgery.

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

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

Effects of Deferoxamine on Fat Graft Survival.

The most important problem in fat transplantation is the unpredictable rates of resorption. Deferoxamine (DFO) is an iron-chelating agent with many useful functions including stimulating angiogenesis and antioxidant nature. The purpose of the study is to evaluate the effects of DFO on fat graft viability in rat model. A total of 24 Wistar rats were divided into three groups and 0.5 g of the left inguinal fat pad was extracted. In control group, fat grafts were implanted to the parascapular area without performing any procedure. In sham group, they were implanted in 0.2 mL saline solution followed by serial saline injections for 1 month. In the study group, fat grafts were implanted in 0.2 mL saline solution and 300 mg DFO followed by serial DFO injections for 1 month. At the postoperative second month, fat grafts were taken back and sent for histopathologic examination. The weight measurements of biopsy specimens in the study group demonstrated significantly higher than in the other two groups. Inflammation and fibrosis rates were also found to be significantly higher in the study group compared with the other groups; however, no significant difference in the apoptosis rates was detected between the groups. Fat grafts enriched with DFO showed significant increase in fatty tissue content in the study group compared with the control and sham groups. DFO increases the fat graft survival in rats and it may be a useful addition in autologous fat grafting procedures to increase fat graft viability and obtain maximal long-term durability.

Effects of Different Concentrations of Injectable Collagenase Enzyme on Capsular Tissue Around Silicone Implants: A Preliminary Experimental Study for the Development of a New Treatment Strategy.

OBJECTIVES: In recent studies, collagen organization was blamed for the formation of capsular contracture which is still a challenging problem after silicone implant-based breast operations. In this study, effects of different concentrations of collagenase enzyme derived from Clostridium histolyticum on the capsular tissue formation around the silicone implants were investigated. The injectable form of collagenase has a routine clinical use in the treatment of both Dupuytren's and Peyronie's diseases. MATERIALS AND METHODS: Thirty-two Wistar albino rats were randomized into four groups. A 2 × 1 × 0.3-cm-sized silicone block was inserted inside a dorsal subcutaneous pocket in all groups. After 2 months of insertion, capsule thicknesses around the implants were detected under ultrasonography. This was followed by injection of isotonic saline, 150, 300, and 600 IU in Gr-1, 2, 3, and 4, respectively. All the animals were sacrificed at the end of the first week for histologic sampling to determine fibroblast proliferation, vessel density of the tissue, necrosis, edema, inflammation, and capsule thickness. All the data were statistically analyzed using Kruskal-Wallis and Mann-Whitney U tests and compared for significance of the results. RESULTS: There was no significant difference in terms of capsule thinning between the 300 and 600 IU groups but in both groups thinning was significantly higher than the sham group. In the 150 IU group there was no significant thinning as compared to the sham group (p > 0.05). However, complications such as skin necrosis, infection, and seroma formation were seen only in the 600 IU injection group. The optimal safe and effective dose of the enzyme was accepted as 300 IU. The 300 IU injection provided up to 89 % thinning in the capsule tissue. There was thinning of the collagen bundles parallel to capsule thickness. In the 600 IU group, micro-pores were encountered at the thinnest points. CONCLUSION: However, the late results and recurrence rates of capsular contracture were not included in this study; collagenase seemed effective for the reduction of capsular tissue around the implants. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

Defect closure with "8-shaped crisscross tensile suture" technique.

BACKGROUND: Sutures and suturing techniques compose the basis of the surgery. Although many surgical methods such as the skin grafts or flaps has been described for the closure of large defects, proper primary suturing may sometimes yield very successful results and decrease the need of complicated procedures. In this article, a new combined skin-subcutaneous tissue suturing technique called as "8-shaped crisscross tensile suture (8CTS)" designed for the closure of large skin defects is presented. PATIENTS AND METHODS: One hundred forty-nine patients with an age distribution between 14 and 65 y were operated for large skin defects by using the 8CTS technique. The most common etiology of the defects was free flap donor sites, and the most common defect localization was the anterolateral thigh region. The average defect width on the axis of primary closure was calculated as 14.6 cm. The 8CTS technique is a combination of both skin and subcutaneous layers suturation and may even involve deeper layers suturation according to the depth of the defect. RESULTS: Eight complications including wound dehiscence, early recurrence of pilonidal sinus disease, seroma formation, skin-edge necrosis, and incisional hernia were observed. The wounds of 141 patients were treated successfully. CONCLUSIONS: The 8CTS technique is a useful method for the closure of large defects eliminating the need of more complex procedures and providing acceptable cosmetic results while supporting both skin and subcutaneous tissue in one suture.

A New Option for the Reconstruction of Orbital Floor Defects: The Olecranon Bone Graft.

BACKGROUND: Orbital floor fractures are one of the most commonly encountered maxillofacial fractures due to its weak anatomic structure. Autogenous bone is a commonly used option for the reconstruction of orbital floor defects by many authors and institutions. This article introduces the olecranon bone graft as a new option for orbital floor reconstruction. METHODS: The study is based on the analysis of 13 patients with orbital floor fracture operated on by using the olecranon bone graft. The mean age of the patients was 34 years 6 months. The physical examination of 5 (38.5%) patients revealed diplopia, 3 (23%) patients gaze restriction, 3 (23%) patients infraorbital nerve paresthesia, and 7 (53.8%) patients enophthalmos with various degrees. The mean defect size was 21.15 × 14.08 mm and the mean defect field was 2.98 cm2. All patients were operated on under general anesthesia and the orbital floor defect was exposed subperiosteally. The olecranon bone graft was harvested in 10 cases using a 3-cm incision over the olecranon and in 3 cases using the bone biopsy trephine and placed to the orbital floor defect after shaping with cottle cartilage crusher. Both clinical and radiological follow-up examinations were carried out in the postoperative period. RESULTS: The mean follow-up period of the patients was 7.92 months. The mean size of the grafts was 24.85 × 17.54 mL. The mean field of the grafts was 4.26 cm2. Among the 7 patients who had enophthalmos before the surgery, complete resolution was observed in 6 (85.7%) patients and in the remaining 1 (14.3%) patient, the degree of enophthalmos was found to be significantly reduced at the postoperative sixth month examination. All patients with preoperative diplopia and gaze restriction showed complete healing in the postoperative period. Eleven (84.6%) patients showed mild pain at the olecranon donor area with complete relief in the postoperative 3 days and the remaining 2 (15.4%) patients had moderate pain sensation which completely passed away at the postoperative fifth day. CONCLUSIONS: The olecranon bone graft is a suitable autogenous option for orbital floor reconstruction due to its considerable strength and molding capacity with low rates of complications and donor area morbidity.

Idiopathic sixth nerve palsy after bimaxillary surgery: a complication or a sequential pathology independent from surgery?

This was a case of a 21-year-old female patient with a very rare and unexpected symptom "diplopia occurring due to the idiopathic sixth nerve palsy" encountered after 2 weeks following bimaxillary surgery performed for the correction of class III malocclusion deformity.

Awful face of the war-impacted smoke bomb capsule in the face and systemic toxicity: reports from the conflict in Syria.

In this study, a rare kind of injury due to smoke bomb capsule impaction to midface and under the cranial base is presented, and maneuvers to reduce mortality are discussed. Three male patients were presented with impacted smoke bomb capsules into the midface and under the cranial base structures. Midface structures, anterior cranial base, and, in 2 patients, unilateral eye were severely damaged. Two patients died after the initial emergency operations because their lung disease progressed to acute respiratory distress syndrome. One of the patients lived, and soft tissue reconstruction was achieved by using temporal transposition and cheek advancement skin flaps with split-thickness skin graft from donor site. However, craniofacial destruction is important in these patients; a multidisciplinary approach is needed for the treatment of direct smoke bomb injuries because the patients experienced chemical burn and acute trauma. The timing of maxillofacial reconstruction is also a question in these specific patients.

A New Modification of C-V Flap Technique in Nipple Reconstruction: Rolled Triangular Dermal-Fat Flaps.

In this study, a simple modification of the C-V flap technique designed to maintain the neo-nipple projection performed as the last stage of breast reconstruction is described. The technique was used in seventeen patients who were treated with breast reconstruction using the transverse rectus abdominis flap. Except for one patient with a 2.3 mm decrease in nipple projection, the projection of all neo-nipples was preserved at the end of the mean follow-up period of 19.4 months. According to the results of our study, modifying the C-V flap technique by adding rolled triangular dermal-fat flaps improves the long-term maintenance of neo-nipple projection.

Continuous Suction Drainage of Postoperative Hematoma and Seroma Using Cystofix Device.

UNLABELLED: In this study, an easy and useful method used for the drainage of seroma and hematoma formations occurring after operations requiring extensive tissue undermining is presented. The method utilizes the trocar of the conventional suprapubic urinary catheterization system in combination with the catheter of the negative pressure vacuum drainage system. It provides quick, safe, and painless seroma and hematoma evacuation and can easily be performed in office setting. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Comparison of the flap survival with ischemic preconditioning on different pedicles under varied ischemic intervals in a rat bilateral pedicled flap model.

The study was undertaken to search whether pedicle selection for ischemic preconditioning (IP) and duration of global ischemia applied after IP influenced efficacy of IP on flap viability in epigastric adipocutaneous island flap with bilateral pedicles in rat model. In total, 159 rats were divided into one control and three (primary, secondary, or bilateral pedicle) IP treatment groups. IP was performed on different pedicles by three cycles of 10 minutes of pedicle clamping and 10 minutes of release. After IP procedure secondary pedicle was ligated in all groups, and flaps were exposed to 0, 1, 2, 4, or 6 hours of global ischemia by clamping primary pedicle. In control groups, after the perfusion of bipedicled flaps for 1 hour, left pedicle was ligated and flaps were exposed to global ischemia as in IP groups. On day 5 post-surgery, tissue samples and topographic measurements were taken. No significant differences in semi-quantitative scorings of polymorphonuclear leukocytes infiltration, chronic inflammation, interstitial edema, neovascularization, VEGF, and CD105 expression levels among groups were found (P > 0.05). Percentages of necrosis were consistently smaller in IP groups compared to controls for the same duration of global ischemia, with exception of the no-ischemia. Area of necrosis was significantly smaller in primary IP group versus secondary IP group in the absence of global ischemia (P < 0.01). In the presence of global ischemia, both primary and secondary pedicle IP groups had significantly smaller percentage of necrosis than controls (P < 0.05) and there was no significant difference between primary and secondary IP groups (P > 0.05). Thus, IP performed on different pedicles may ameliorate flap survival in a comparable fashion, depending on the duration of global ischemia. Secondary pedicle IP was as effective as primary pedicle IP and may be feasible in free flap transfers.

Congenital isolated aplasia of lower lateral cartilage and reconstruction using dorsal hump material.

Congenital nasal abnormalities are very rare in the literature. There are 3 reported cases of isolated partial lower lateral cartilage defects. In this article, we report the case of a patient with congenital complete absence of the lower lateral cartilage. The patient had severe external nasal valve dysfunction and a concavity of the alar vault, even in the resting position. The defect was reconstructed using resected and reshaped nasal dorsal hump material. At the end of a 12-month follow-up period, the patient was satisfied with the functional and aesthetic results of the operation. No external or internal nasal valve collapse occurred during inspiration. Such developmental abnormalities may be syndromic and require special attention for reconstruction.

An underestimated "ghost" foreign body as an unusual cause of mandibular osseocutaneous fistula formation: impacted spike of a soccer cleat.

In this article, the case of a patient with osteocutaneous fistula at the left malar region secondary to impacted spike of a soccer cleat to the mandible is presented. Both the clinical and radiologic diagnoses failed because of an obscure anamnesis of the patient and the unavailability of viewing the spike in orthopantomogram and computed tomography. Surgical extirpation was performed to the 41-year-old man who was injured in a football match 3 months before the presentation and had a swooning history after an accidental booting. There were no early or late complications after the surgery at the end of 9 months. This study shows the importance of both obtaining a definite history of patients and sequential radiologic imaging to make a differential diagnosis between the foreign bodies and cystic or noncystic tumors and inflammatory lesions of the mandible.

Hezarfen wings: a lower lateral cartilage-based cartilage suspension technique for the adjustment of nasal tip rotation and projection and the correction of supratip deformity.

Nasal tip surgery is one of the most important parts of rhinoplasty to achieve an attractive nose. There are numerous techniques focusing on the correction of nasal tip rotation and projection. In this article, a new cartilage support derived from the cephalic border of lower lateral cartilages is used for the adjustment of tip rotation and projection, whereas improving supratip fullness is presented. Bilaterally harvested cartilage extensions are resembled as bird's wings and dedicated to the wings that were created by the world's first scientist who flew from one continent to another: Hezarfen Ahmed Çelebi. Thirty-two patients who underwent open-approach rhinoplasty operation including the abovementioned method were evaluated retrospectively. After performing conventional steps of open approach rhinoplasty, a wing is created by making a cephalic incision parallel to the lateral crural axis leaving the medial attachment intact and then undermined. Then, the cartilage is turned over the midline bilaterally as it acts like a curb by pulling or releasing the wings to adjust to the desired tip rotation and projection and sutured to the repaired upper lateral cartilage roof. Other 2 types of using these wings were asymmetric suturing one of the wings to help in the redirection of deviated nasal tip (n = 12) and suturing each other at midline to support the overlying skin like a tent with supratip deficiency (n = 7). The authors presented here both esthetic and functional outcomes of Hezarfen wings' method that was used for both nasal tip adjustments and supratip support.