Effects of microneedle length and duration of preconditioning on random pattern skin flaps in rats.

To date, the surgical delay of skin flaps is the most common and reliable method that increases skin flap survival. In this study, we aimed to increase skin flap viability using preconditioning by microneedling. Seventy-two Sprague Dawley rats were randomly divided into control, surgical flap delay (SFD), and four microneedling groups (7 or 14 days of preconditioning with 0.5 mm or 1 mm needles). Modified McFarlane flaps were raised on the back of rats. In Group I, a caudal pedicled skin flap was raised and the flap survival rate was assessed on postoperative day 14. In the SFD group, a bipedicled flap was created and after 14 days of surgical delay, all skin flaps were raised. In the microneedling groups, 0.5 mm or 1 mm needles were used for 7 or 14 days. The flap survival rates of all microneedling and SFD groups were significantly higher than the control group. The plasma levels of vascular endothelial growth factor (VEGF) did not significantly differ between groups, but the VEGF level of skin samples in the SFD group was higher than the control group. The vessel counts of all microneedling and SFD groups were statistically higher than the control group in all skin samples taken before raising the flaps, but skin samples taken 14 days after raising the skin flap did not show any difference between groups. We showed that preconditioning by microneedling can be used to improve the viability of critical ischemic skin flaps at a level similar to surgical delay.

Delayed Primary Closure of Traumatic Tension Wounds Using Plastic Straps and Kirschner Wires.

Tension of the wound edges should be overcome with precise surgical planning, which is recognized as one of the major contributors to local complications by compromising circulation of the wound edges. In this article, it was aimed to present the clinical results of a surgical technique, in which the plastic straps and Kirschner wires are used for delayed primary closure of traumatic tension wounds. Depending on the assessment of the wound localization, wound dimension, and mobility of adjacent soft tissue, the technique was performed in 9 patients with a male to female ratio of 8:1. Gunshot injury was the leading cause (n = 5), and in most cases, the wounds were located at the lower extremities (n = 6). The mean time between performing the technique and closing the wound primarily and the mean hospitalization time were 4.8 ± 1.1 and 13.5 ± 3.9 days, respectively. In each case, wound closure and healing were achieved successfully without any serious complications. The presented technique provides advantages of using a low cost as well as a very simple equipment, improved and reliable stability during tightening process due to self-locking feature of the plastic straps, no donor site morbidity, short operating time with low rate of post-operative complications, and short hospitalization time. We recommend using this invaluable technique reliably for the treatment of traumatic tension wounds. However, further studies are needed for better evaluation of cosmetic and functional outcomes of the presented technique.

Il faut une planification chirurgicale précise pour éviter la tension au pourtour des plaies, qui est reconnue comme l'un des principaux éléments responsables des complications locales. En effet, la tension compromet la circulation au pourtour des plaies. Dans le présent article, les auteurs ont cherché à présenter les résultats cliniques d'une technique chirurgicale qui fait appel à des bandes de plastique et à des broches de Kirschner pour retarder la fermeture primaire des plaies de tension traumatiques. Compte tenu de l'évaluation du foyer de la plaie, de la dimension de la plaie et de la mobilité des tissus mous adjacents, neuf patients (huit hommes et une femme) ont été soumis à cette technique. Les blessures par balle étaient la principale cause des plaies (n = 5), et dans la plupart des cas, celles-ci étaient situées sur les jambes (n = 6). La période moyenne entre l'exécution de la technique et la fermeture primaire de la plaie était de 4,8 ± 1,1 jours et le séjour hospitalier moyen, de 13,5 ± 3,9 jours. Dans chaque cas, la plaie s'est fermée et a guéri sans complications graves. La technique présentée a l'avantage de faire appel à du matériel peu coûteux et très simple, à assurer une stabilité fiable et plus importante pendant le processus de resserrement grâce à l'autoblocage des bandes de plastique, à éviter la morbidité au site du donneur, ainsi qu'à favoriser une opération de plus courte durée, un faible taux de complications et un court séjour hospitalier. Les auteurs recommandent cette technique inestimable pour traiter les plaies de tension traumatiques. Il faudra toutefois mener des études plus approfondies pour mieux en évaluer les résultats esthétiques et fonctionnels.

High Voltage Electric Burn Repair of the Forehead by Reverse Flow Temporalis Muscle Flap.

Repairing soft tissue defects of the forehead which exposes the bare bone is a dilemma with few reconstructive techniques for plastic surgeons. Forehead is an important aesthetic unit of the face which is covered with the glabrous skin. Due to the relative lack of similar mobile tissue locally, reconstruction of large soft tissue defects of the forehead region by local flaps is demanding. Temporalis muscle flap does not reach to the midline of the forehead region because of the insufficient length of the deep temporal vascular system. During the transfer of the muscle, only a small volume and size of the muscle can reach to the defect, remaining most of the muscle bulk in the pedicle and a relatively limited arc of rotation, thus a small volume of usable tissue at the distal portion of the flap. We successfully used reverse flow temporalis muscle flap for the purpose of eliminating the above-mentioned disadvantage of temporalis muscle flap in a 23-year-old male patient who sustained a high-voltage electrical burn resulting 12 × 8 cm left forehead defect exposing the bare bone.

Assessment of markers expressed in human hair follicles according to different skin regions.

BACKGROUND: Body region-dependent hair follicle (HF) characteristics are concerned with follicular size and distribution, and have been demonstrated to have characteristics for each region of the body. OBJECTIVES: The aim of the present study was to investigate the expression patterns of the markers called cytokeratin 15 (K15), cytokeratin 6 (K6) and monoclonal antibody Ki-67, and also apoptosis in HFs, which can be observed in different parts of the human body. MATERIAL AND METHODS: In this study, healthy human HFs were taken by biopsy from 5 various donor sites of the human body: the scalp, the leg, the abdomen, the back and waist. HF-containing skin specimens taken using cryosection were stained with hematoxylin & eosin (H&E) and K15, K6, Ki-67 and terminal deoxynucleotidyl transferase-mediated digoxigenin-dNTP nick end-labelling (TUNEL) immunofluorescence staining protocol was performed. RESULTS: Different skin regions from the human body were examined histologically. While the HFs of scalp tissue showed anatomically obvious hair layers, some hair sections from other regions, like the leg, the abdomen, back and waist, were not as distinct as in the scalp region. According to our findings, K15 expression was highest in the scalp. In addition, the immunoreactivity (IR) intensity of K15 was significantly decreased in the HFs on the waist and abdominal regions, compared to the scalp and back regions (p < 0.001). However, the IR intensity of K6 in the scalp region was statistically significantly higher than the IR intensity of K6 in the abdomen region (p < 0.05). Moreover, we showed intraepithelial apoptosis and proliferation of keratinocytes in the bulge of HF. In the study, Ki-67-positive and TUNEL-positive cell numbers were not statistically significant (p > 0.05). CONCLUSIONS: Our findings are important for further investigation of molecular aspects of the human hair follicle stem cells compartments in health and disease, which might be a promising model for comparative studies with different human diseases.

Steel Wool-Aided Dermabrasion of Deep Partial-Thickness Burns.

Early tangential excision of the burn wound is essential for removal of necrotic tissue and promotion of burn wound healing process. However, the depth of the burn wound is not easily assessed during the tangential excision performed by hand-held dermatomes, and it may be possible to excise unburned vital dermis unnecessarily, which aids in primary epithelization of the burn wound by adnexal structures. We herein present early clinical results of steel wool-aided dermabrasion in patients with deep partial-thickness burns. This is a retrospective case study of 23 consecutive hospitalized patients with deep partial-thickness burns. All of the steel wool-aided dermabrasions were performed under general anesthesia within 48 hours after injury. Patients were excluded from the study if the admission was not within 24 hours after injury, and if the burn wound was entirely superficial partial- or full-thickness. Thirteen male and 10 female patients with a mean age of 26.2 ± 17.1 years were enrolled in the study. During the follow-up period, all of the patients had burn wounds primary epithelized on postburn day 15.1 ± 1.8, without any complications. None of the patients exhibited a mortal course, and redebridement or skin grafting of the previously dermabraded deep partial-thickness burn wounds were not required in any of the patients. Steel wool-aided dermabrasion is an easy, cost-effective, and reliable technique for the treatment of deep partial-thickness burns, which provides complete removal of necrotic tissue, preserves the vital dermis, reduces the requirement for skin grafting, and decreases length of hospital stay.

Guideline and treatment algorithm for burn injuries.

As in many other countries, burn injuries are a challenging healthcare problem in Turkey. Initial management of burn patients is very important for future morbidity and mortality. Therefore, the Turkish Ministry of Health prepared "National Burns Treatment Algorithm" aided by the Scientific Burns Council. The basic aim of this algorithm is to guide physicians in the treatment of burn victims until they reach an experienced burns center. The content of this algorithm is first aid, initial management, resuscitation, and transfer policy. The Council started to work on this algorithm in 2011. Various consultants, including general surgeons, pediatric surgeons, aesthetic, plastic and reconstructive surgeons, anesthesiologists, and intensive care physicians, revised the first draft and it was sent to eight education and research hospitals of the Ministry of Health, four universities, and seven non-governmental organizations. In the last quarter of 2012, the algorithm was finalized and approved by the Scientific Council, after which, it was approved by the Ministry of Health and published.

Novel biogeometric designs of first dorsal metacarpal artery flap in hand reconstruction.

Reconstruction of the soft tissue defects of the first web space and proximal dorsal thumb is still one of the most challenging problems in reconstructive surgery. Depending on the defect size, various reconstructive methods have been described, including local, regional, distant and free flaps. The authors described new biogeometric designs of first dorsal metacarpal artery flap for the reconstruction of the soft tissue defects of the first web space and the proximal dorsal thumb. These modifications are bilobed and V-Y advancement first dorsal metacarpal artery flaps. Three patients had burn wound adduction contractures of the first web space and three had acute wounds resulting from electrical burns, the defects of which were located on the first web space and on the dorsum of the thumb. The defect sizes ranged from 2.5 × 2 cm to 3.5 × 4 cm, and were reconstructed with the bilobed and V-Y advancement first dorsal metacarpal artery flaps. None of these flap modifications had any problems related to the perfusion of the flap, such as arterial insufficiency or venous congestion. The mean follow-up period was 16 months and all the patients were satisfied with the functional result and the donor site scars appearance. The bilobed and V-Y advancement first dorsal metacarpal artery flaps described by the authors for the hand reconstruction are safe, easily performed, and are versatile without skin grafts at the donor site because of inherent excellent elasticity and mobility of the dorsal hand skin.

Experience of 80 cases with Fournier's gangrene and "trauma" as a trigger factor in the etiopathogenesis.

BACKGROUND: The purpose of the present study was to retrospectively analyze the patients' data presented with Fournier's gangrene (FG), to compare obtained data with the literature and to investigate the role of "trauma" in the etiopathogenesis. METHODS: A retrospective study was conducted on 126 patients with FG that consulted to our department. RESULTS: There were 76 male and four female patients. The mean age of the patients was 53.5±13.6 years. The most common presentation of patients was swelling (n=74). The scrotum has been shown to be the most commonly affected area in the patients (n=75). Diabetes mellitus was the leading predisposing factor and trauma was the leading responsible cause for FG. Escherichia coli was the most frequently identified microorganism (n=43, 53.75%). Primary closure was the most common technique used for all patients. Three patients exhibited a mortal course due to sepsis and multi-organ failure. CONCLUSION: FG still has a high mortality rate. Rapid and correct diagnosis of the disease can avoid inappropriate or delayed treatment and even death of the patient. The healthcare professionals should be aware that any trauma in the perineal region could lead to FG.

Retrospective analysis of burn injuries caused by hot milk in 159 pediatric patients: 14 years of experience in a burn unit.

BACKGROUND: The aim of this study was to investigate the hot milk burns among the pediatric patients and to compare our experiences with similar studies in the literature. METHODS: A 14-year retrospective study was conducted on 159 pediatric patients with hot milk burn who hospitalized at the Burn Unit of Erciyes University Medical Faculty. RESULTS: There were 81 male and 78 female patients with a male to female ratio of 1.03:1. The mean age of the patients was 2.7±1.6 years. The initial injury was immersion in 59.7% of the patients and spillage in 40.3%. The mean burned body surface area of the patients was 18.6±10.8%. Twenty-two percent of the patients had moderate, and 78% had major burn trauma. Forty-nine percent of the patients received burn wound debridement and reconstruction with auto-skin grafts. Our burn unit's mortality rate was 1.5% among 542 pediatric patients with hot water, and 5.6% among 159 pediatric patients with hot milk burn during the same period, respectively. CONCLUSION: Hot milk burns should be considered as separately from other hot liquid burns which do not contain fat such as water, tea, and coffee. Physical and chemical properties of milk because of its high content of fat give rise to more tissue destruction, increased morbidity and mortality.

Stromal vascular fraction improves deep partial thickness burn wound healing.

OBJECTIVE: The practice of early burn wound excision and wound closure by immediate autologous skin or skin substitutes is the preferred treatment in extensive deep partial and full-thickness burns. To date there is no proven definite medical treatment to decrease burn wound size and accelerate burn wound healing in modern clinical practice. Stromal vascular fraction is an autologous mixture that has multiple proven beneficial effects on different kinds of wounds. In our study, we investigated the effects of stromal vascular fraction on deep partial-thickness burn wound healing. METHODS: In this study, 20 Wistar albino rats were used. Inguinal adipose tissue of the rats was surgically removed and stromal vascular fraction was isolated. Thereafter, deep second-degree burns were performed on the back of the rats by hot water. The rats were divided into two groups in a randomized fashion. The therapy group received stromal vascular fraction, whereas the control group received only physiologic serum by intradermal injection. Assessment of the burn wound healing between the groups was carried out by histopathologic and immuno-histochemical data. RESULTS: Stromal vascular fraction increased vascular endothelial growth factor, proliferating cell nuclear antigen index, and reduced inflammation of the burn wound. Furthermore, vascularization and fibroblastic activity were achieved earlier and observed to be at higher levels in the stromal vascular fraction group. CONCLUSIONS: Stromal vascular fraction improves burn wound healing by increasing cell proliferation and vascularization, reducing inflammation, and increasing fibroblastic activity.

Fractures of the mandible: a 20-year retrospective analysis of 753 patients.

BACKGROUND: The craniofacial region is one of the most frequently injured parts of the body, and mandibular fracture is one of the commonest facial skeletal injuries. The most frequent causes of mandibular fractures are the traumas related to traffic accidents, falls, interpersonal violence, and sports activities, etc. METHODS: Seven hundred fifty-three cases (615 male, 138 female; megan age 36.2 years) (age >16) with mandibular fracture were evaluated retrospectively. Patient records were examined in terms of age, sex, etiology, seasonal variation, fracture localization, accompanying traumas, treatment modality, and postoperative complications. RESULTS: Traffic accidents were the most common etiologic cause in all age groups and both sexes. All cases had a total of 1090 fractures, and the most common fracture localization was the parasymphysis (28.6%), followed by the condyle, corpus, angulus, symphysis, dentoalveolar process, ramus, and coronoid process, respectively. In 25 (3.3%) patients with fissure-like, non-displaced fracture, only symptomatic treatment was applied. Closed reduction with elastic bandage, arch bar, quick-fix screws or Ivy Loop was the only method performed in 280 (37.2%) patients. Osteosynthesis by open reduction and internal fixation (miniplates, screws or transosseous wiring) was performed in 403 (53.5%) patients; closed reduction techniques were also performed in 134 of these patients. CONCLUSION: In the recent years, double-road constructions, increased traffic audits and regulation of the traffic rules decreased the incidence of mandibular fractures.

Retrospective analysis of two hundred thirty-five pediatric mandibular fracture cases.

Maxillofacial fractures are encountered less commonly during childhood period due to anatomic, social, cultural, and environmental factors. Although the incidence of all maxillofacial fractures is 1% to 15% among pediatric and adolescent patients, this rate drops to less than 1% in children below 5 years age. Two hundred thirty-five cases (

A new proposal of classification of zygomatic arch fractures.

PURPOSE: Among facial fractures, zygomatic arch fractures occur rather frequently. Facial fractures have recently been classified in fine detail according to computed tomographic findings. Nevertheless, there exists no classification of the zygomatic arch fracture, which has a physiognomically important place, to provide guidance for treatment. We aimed to make a detailed classification of zygomatic fractures in various shapes, which does not exist in the literature, and to form an algorithm for treatment. PATIENTS AND METHODS: A total of 451 patients with zygomatic arch fractures treated in our clinic from 1987 through 2004 were assessed retrospectively from the treatment viewpoint together with radiological and clinical findings. RESULTS: At the end of this assessment, arch fractures were divided into 2 groups: 1) isolated fractures in which the zygomatic arch alone broke, and 2) combined fractures in which the zygomatic arch broke together with the other facial bones. Isolated fractures were also divided into 2 subgroups as A) 2 fractures in the arch, and B) more than 2. Isolated arch fractures with more than 2 fracture lines were also classified as V-shaped fractures where fragments are partially reduced and those where fragments are displaced. As for combined fractures, they were subgrouped as A) single fracture in the arch, and B) plural. Plural fractures were further classified within their own group, also according to whether fragments were displaced or not. CONCLUSION: In the 2 fractures and V-shaped fracture subgroups of isolated fractures, preservation of fragments in reduced position was satisfactory during the closed reduction and afterwards. As for those with more than 2 fractures of isolated arch fractures, they required open reduction and internal rigid fixation. The same treatment was used in combined zygomatic arch fractures where there were more than one displaced fractures. In addition to classification, we formed an algorithm to guide us in treatment based on our series.

Repair of traumatic orbital wall defects using conchal cartilage.

BACKGROUND: The authors' aim was to investigate the efficiency of conchal cartilage grafts in defective orbital wall fractures, which are encountered isolated or in combination with other orbitozygomatic fractures. The authors assessed, for this purpose, the follow-up results of patients treated by using conchal cartilage grafts. METHODS: Ten patients who had defective orbital wall fractures and were treated by using conchal cartilage graft among those treated for facial fractures in the authors' clinic were included in the study. The wall defects in the patients were detected either with preoperative radiologic images or with orbital exploration performed to look for a possible defect accompanying the fracture with orbital extension during the operation. In all patients (four isolated and six combined orbital fractures), who had defects varying from 100 to 400 mm, conchal cartilage grafts were adapted to the defect. In the postoperative follow-up, Hertel exophthalmometry was also performed together with clinical examination so that enophthalmos that might develop as a complication could be assessed. RESULTS: In the postoperative period, cartilage graft was palpated slightly in two patients at the edge of the infraorbital rim. Limitation in eye movement, diplopia, and enophthalmos did not occur in our patients, except for one who reported to us 1 year after the primary trauma. No complication in the donor area was observed. CONCLUSIONS: Conchal cartilage could be considered one of the autogenous materials among those materials suitable for the repair of defective orbital wall fractures that are not oversized. It has the advantages of being adequate for reconstruction of the fracture, easy to obtain, easily adaptable to the orbital walls, and having minimum morbidity at the donor site.

Pectoralis major musculocutaneous flap with nipple-areola complex in head and neck reconstruction: preliminary results of a new modified method.

Pectoralis major musculocutaneous flap remains the workhorse tool for head and neck reconstruction. Flap failure in head and neck reconstruction is a devastating complication with a high morbidity and mortality. Inclusion of nipple-areola complex on the skin paddle stabilizes the blood circulation in the skin island of the pectoralis major musculocutaneous flap. A modified use of pectoralis major musculocutaneous flap with nipple-areola complex on the skin island was performed in 11 male patients in head and neck reconstructions with success without partial or total skin island necrosis. We recommend the inclusion of nipple-areola complex on the skin island of the pectoralis major musculocutaneous flap in head and neck reconstructions to increase the blood supply of the skin paddle. We concluded that the skin island of the pectoralis major musculocutaneous flap might include the areola and nipple complex in patients with large defects of the head and neck, which stabilize the blood circulation in the skin island.

A surgical conundrum: Tessier number 4 cleft.

OBJECTIVE: Among the rarest of the craniofacial clefts is the Tessier no. 4 cleft; and hence little has been published about its management and treatment. Complete forms of the cleft yield poor surgical results because of the shortened oculoalar and oculo-oral distance and inadequate soft and bony tissue. Multiple sequential corrective operations are required. A primary early concern is the protection of the eye, particularly in severe forms in which corneal exposure occurs. This article presents two cases of Tessier no. 4 clefts, one unilateral and the other bilateral, and discusses the problems encountered during their surgical and postoperative managements.

Distally based perforator medial plantar flap: a new flap for reconstruction of plantar forefoot defects.

In this article the author describes 2 cases of a distally based perforator medial plantar flap that were transferred successfully from the nonweight-bearing instep region to the weight-bearing plantar forefoot (defects, 8 x 5 cm and 6 x 5 cm respectively). This flap is nourished solely by perforators of the medial plantar vessels. The advantages of this flap are the protection of the vascular supply of the foot (because both posterior tibial and medial plantar vascular systems are preserved), anterograde flow of the vascular supply (which gives an additional advantage of expecting less venous insufficiency compared with reverse-flow flaps), no dependence on retrograde vascular communications, minimal donor site morbidity, and transport of structurally similar tissues to the plantar forefoot.