Effects of delayed breast reconstruction on the thoracolumbar vertebrae in patients undergoing unilateral mastectomy: A retrospective cohort study.

BACKGROUND: Post-mastectomy changes vertebral column alignment. There is limited data assessing spine curvature after breast reconstruction. In this study, the effects of delayed breast reconstruction on the Cobb angle and quality of life indicator (Oswestry disability index [ODI]) were evaluated in patients undergoing unilateral mastectomy. METHODS: This study was performed as a retrospective review of 40 patients who had delayed reconstruction for breast cancer at a single center between 2015 and 2018. Patients completed a standardized questionnaire, the ODI, at the beginning and 12 months after the operation. The Cobb angles of the vertebral columns and spinal curve directions were determined using posteroanterior chest radiographs obtained pre- and postoperatively. RESULTS: Mean age and body mass index (BMI) were 49.9 ± 9 years and 30.1 kg/m2, respectively. The Cobb angles were found to differ before and after the reconstruction; the difference was statistically significant, and the average change in Cobb angle was 4.3° (p = 0.03). The Cobb angles were also found to be significantly different between patients with implants and those who underwent autologous tissue reconstruction (p = 0.026). Although delayed reconstruction performed with autologous tissue or implant improves post-mastectomy scoliosis, autologous tissue reconstruction yields better outcomes. The mean preoperative ODI score was 21.6%, and 8.8% patients presented no back pain. The mean score was 3.2% at 12 months postoperation. These results are statistically significant (p<0.001). CONCLUSIONS: Breast reconstruction positively affects vertebral alignment and leads to better posture, physical function and decreased back pain in breast cancer survivors, significantly improving their quality of life.

Non-significant Effects of The Geometric Shape of Autologous Cartilage Grafts on Tissue Healing: An Animal Study.

BACKGROUND: The reconstruction of cartilage defects for cosmetic and/or functional reasons has become routine in plastic and reconstructive surgery. However, it remains challenging due to the slow turnover and low viability of cartilage grafts. Although autologous grafts can be used to determine the shape of the defect in cartilage-reconstruction surgeries, the effect of defect shape on cartilage healing has not been reported. Here, we present the first study aiming to investigate the influence of cartilage graft geometry on healing. METHODS: Twelve New Zealand white rabbits were used in the study. Square-, rectangle-, sphere-, and fusiform-shaped cartilage defects were applied to both ears with 1-cm2 geometric templates that completely elevated the cartilage tissue without damaging the opposite perichondrium. As a control, the removed cartilage was sutured back to the right ear, whereas the left ear was sutured back without any graft. Histological examinations were made on samples taken during surgery and those taken four months post-surgery. Chondrocyte production and organisation, chondrocyte vacuolisation, collagen synthesis, proteoglycan levels, vascularisation, focal bleeding, and peripheral proliferation were scored independently by two histologists. RESULTS: There was no statistically significant difference in the growth rates of either the control or experimental cartilage tissues when compared with that of the initial cartilage tissue (p = 0.083). Histologic comparisons revealed better outcomes in the grafted cartilage groups compared to those receiving the donor cartilage, but this was not statistically significant. CONCLUSIONS: This study demonstrates that the geometric shape of the defect has no significant effect on cartilage healing. 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 .

A rare cause of secondary hemophagocytic lymphohistiocytosis: systemic loxoscelism.

BACKGROUND: Loxoscelism is caused by the bite of a specific spider type called the Loxosceles genus. In Turkey, most cases are seen after L. rufescens bites. Clinical manifestation of the bites ranges from local cutaneous reaction to severe ulcerative necrosis. Systemic loxoscelism may also occur. CASE: Herein, we report a previously healthy five-year-old male patient who developed a secondary hemophagocytic lymphohistiocytosis after a presumed brown spider bite. He was treated with dexamethasone. Within the following 14 days, hemophagocytic syndrome resolved. Local hyperbaric oxygen therapy was applied to the necrotic areas. CONCLUSION: Secondary hemophagocytic lymphohistiocytosis may develop after systemic loxoscelism. In the presence of persistent fever, hepatosplenomegaly and laboratory findings this clinical entity should be kept in mind.

Subungual Glomangiomyoma.

Glomus tumors are relatively rare benign tumors originated from normal glomus bodies. These tumors make up approximately 2% of all hand tumors and are most commonly found in the nail matrix and proximal nail bed of the hands. Histopathologically, they are classified into solid glomus tumor, glomangioma, and the least common type glomangiomyoma. Here we report an unusual case of subungual glomangiomyoma of the toe with dermatoscopic and histopathologic findings.

Physical Effects of Unilateral Mastectomy on Spine Deformity.

OBJECTIVE: Mastectomy is known to effect body posture after a change in the center of gravity of women due to a missing breast. Although previous studies on short-term postural changes in mastectomy patients using photogrammetry or Moiré topography suggested ipsilateral inclination of the trunk, our clinical observations during breast reconstruction surgeries indicated a contralateral shoulder elevation in women with unilateral mastectomy. Because the change in body posture can affect spinal alignment, we aimed to evaluate the long-term physical effects of unilateral mastectomy on spine deformity by radiographic examination. METHODS: Posteroanterior chest radiographs of 60 women (mean age 56.3 ± 8.5 years) taken before and 12 months after the mastectomy were evaluated for Cobb angle and the presence or absence of a tilt from the midline in the coronal plane of vertebral body alignment. RESULTS: Cobb angle decreased in 14 and increased in 38 of 60 patients after unilateral mastectomy, and the angular change was found to be independent of the mastectomy side (P < .001). A shift in Cobb angle to the mastectomy side was observed in 11 of 53 patients (P > .05), whereas a statistically significant shift in Cobb angle to the opposite of the mastectomy side was observed in 33 of 53 patients (P < .001). The results of this observational retrospective study indicated long-term spinal deformation in women with unilateral mastectomy. Two patients with idiopathic scoliosis before mastectomy even developed scoliosis. CONCLUSION: We recommend informing the patients of the possible change in body posture in the long term, which should be supported or limited with physical therapy.

Metamizole: an effective solution for vasospasm.

OBJECTIVE: Vasospasm is a major problem during microsurgery, and a variety of pharmacological agents are used to alleviate vasospasm. This study aimed to demonstrate the effect of metamizole on vasospasm and to compare it with lidocaine and papaverine, both of which are commonly used to correct vasospasm. METHODS: Thirty-five female rats were randomly divided into four groups: Group 1, 2, 3, and 4, which were the control (n = 8), metamizole (n = 9), papaverine (n = 9), and lidocaine (n = 9) treatment groups, respectively. Both femoral arteries of all of the rats were dissected, and they were immediately photographed. The pharmacological agents or saline in the control group were topically applied to the arteries, accordingly. The arteries were photographed again at time points 5, 10, 20 and 30 minutes after application of the agents. The images were transferred to a computer and the arteries' diameters were measured in mm. RESULTS: All of the pharmacological treatments increased the diameter of the arteries significantly during the observation period. However, comparison between the groups indicated that metamizole and papaverine produced significantly more vasodilation than the lidocaine group, for all time points measured after application. CONCLUSION: These findings show that topically applied metamizole is as effective as papaverine at alleviating vasospasm during the 30 minutes time interval. This administration may be considered as a good alternative to correct vasospasm during microsurgery.

Comparison of the effects of systemic sildenafil, tadalafil, and vardenafil treatments on skin flap survival in rats.

OBJECTIVE: The most important issue in flap surgery is flap viability. This study aimed to compare the effects of most commonly used phosphodiesterase type 5 (PDE5) inhibitors on flap survival. METHODS: A 3 × 9 cm flap was elevated from the dorsum of 32 Wistar albino rats. In the control group, saline was administered 2 hours before the flap elevation and continued for 2 days after the surgery. In the sildenafil, tadalafil, and vardenafil groups, the related drug was administered. Blood flow in the flaps was monitored with laser Doppler flowmetry. On postoperative day 7, flaps were photographed and biopsies were obtained. RESULTS: The ratios of flap necrosis area in the tadalafil, sildenafil, and vardenafil groups were lower than that in the control group, but without significant difference (p = 0.077). Histopathological evaluation revealed no significant difference among the groups. CONCLUSION: The ratio of flap necrosis area tended to be lower in the groups receiving oral PDE5 inhibitors than in the control group, although not statistically significant. The role of PDE5 inhibitors needs to be evaluated in larger studies before a conclusion can be made regarding their effects on flap viability.

Intraosseous cavernous hemangioma: a rare presentation in maxilla.

OBJECTIVE: Hemangiomas are benign vascular lesions mostly arising from soft tissues. However, intraosseous hemangioma is a rare entity, comprising only 1% of benign bone tumors. We describe here the presentation, diagnosis, and treatment of a 42-year-old woman with a painless hard swelling-diagnosed to be intraosseous hemangioma via orbital magnetic resonance imaging-localized on the left infraorbital margin. METHODS: After en bloc excision of the mass with safety margins through a subciliary incision, the defect was reconstructed via Medpor, which was fixed to the drilled bones with polypropylene sutures. RESULTS: Histopathological diagnosis of the specimen revealed intraosseous cavernous hemangioma. There seems to be no recurrence or any cosmetic deformity 3 months postoperatively. CONCLUSION: Total surgical excision is the preferred method of treatment for intraosseous hemangiomas with reconstruction. In this patient, we used Medpor for reconstruction of orbital floor, the infraorbital orbital rim and anterior wall of maxillary sinus. We think that Medpor is a good option since a natural smooth malar contour and adequate orbital rim can be achieved and there is no any other scar.

Endometriose cutânea / Cutaneous endometriosis

A endometriose é definida como a presença de glândulas endometriais e estroma fora da cavidade uterina. Essa doença, comum nas mulheres, é geralmente observada durante os anos reprodutivos. Embora a pelve seja o sítio mais comum da endometriose em mulheres, a localização extrapélvica é menos frequente e ainda mais difícil de diagnosticar, em decorrência das apresentações distintas. Neste artigo é descrito um caso de endometriose de cicatriz da parede abdominal.

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterine cavity. This disease is commonly observed in women, particularly those of reproductive age. The pelvis is the most common location for endometriosis. On the other hand, extrapelvic endometriosis, which is less common, is more difficult to diagnose because of the extreme differences in its presentation. In this article, we describe our experience of a case of endometriosis in an abdominal wall scar.

Tolerance of prefabricated skin flaps to ischaemia and reperfusion: experimental study.

Custom prefabrication of tissues allows the surgeon to build what is required for the reconstruction and has enabled the surgeon to reinforce new blood supply into selected blocks of tissue without vessel anastomosis. However, prefabricated flaps have several drawbacks and characteristics that differentiate them from conventional flaps. The objective of this study was to test the tolerance of prefabricated flaps to ischaemia/reperfusion injury in rats. In the first stage, the unilateral-inferior-epigastric pedicle was ligated and divided, and then a skin flap was fabricated by implantation of distally ligated femoral arteriovenous pedicle beneath the abdominal skin. The femoral vessels were implanted either in skeletonised or in muscle-cuffed fashion beneath the abdominal skin, a portion of which was raised as an island flap, based on these vessels. Prefabricated flaps (3×6 cm) were raised 6 weeks after, and were subjected to 10 h ischaemia and followed by 12 h reperfusion. Flap survival and histological changes at the pedicle-skin junction were evaluated at 7 days. Flap necrosis in the sham group was 0%, whereas the control group (conventional) had 47.27±13.50% necrosis. Flaps prefabricated with skeletonised femoral pedicle demonstrated an insignificant pattern with 63.74±10.62% necrosis when compared with prefabricated flaps with muscle-cuffed pedicle with the percentage of necrosis of 64.51±11.24. The area of necrosis was significantly increased when both the prefabricated flaps were compared with the control group or with the sham-prefabricated group (p<0.05). Skin flaps prefabricated with either pedicle-alone or pedicles with muscle cuff are more susceptible to ischaemia and following reperfusion in comparison with the normal flaps.

Is it possible to prefabricate a vascularized peripheral nerve graft?

The ideal technique to repair a damaged peripheral nerve is primary repair. Unfortunately, most damaged peripheral nerves have gaps making primary repair impossible. Autologous nerve grafts that are used to repair damaged nerves can either be conventional nonvascularized nerve grafts or vascularized nerve grafts. Vascularized nerve grafts are proposed to be superior to conventional nerve grafts especially in recipient beds that are scarred, with poor vascular supply. One of the disadvantages of vascularized nerve grafts is the limited donor site. It is possible to eliminate this problem by prefabricating vascularized nerve grafts. In this study, to prefabricate a vascularized nerve, segments harvested from left sciatic nerves of 10 Wistar albino rats were implanted on right femoral vessels, and intact right sciatic nerves were used as controls to evaluate the function, electrophysiologic studies, and histopathologic examination, were performed on these grafts 4 weeks after implantation. Prefabricated sciatic nerve grafts showed vascularization, but they did not show compound action potential activity to electrical stimulation and demonstrated diffuse and severe vacuolar degeneration and myelin loss. We were unable to prefabricate a functional vascularized nerve graft by this method.

Histopathological and electrophysiological study of CO(2), Er:YAG, and CO (2) + Er:YAG laser effect on peripheral nerve.

BACKGROUND: The purpose of this study was to investigate the morphological, histopathological, and electrophysiological changes of peripheral nerve after CO(2) (carbon dioxide), Er:YAG (erbium:yttrium aluminum garnet), and CO(2) + Er:YAG laser irradiation. There have been no comparative reports on CO(2), Er:YAG, and CO(2) + Er:YAG laser effects on peripheral nerve. METHODS: Thirty Wistar albino rats were randomly assigned to three groups. Group I received CO(2), group II Er:YAG, and group III CO(2) + Er:YAG laser irradiation. Contralateral untreated sciatic nerves from the same animals were used as controls. The effect of laser on the peripheral nerve was assessed morphologically, histopathologically, and electrophysiologically after 6 weeks of laser irradiation. RESULTS: No significant difference was observed between the treated and the untreated nerves. CONCLUSION: The overall findings indicated that CO(2), Er:YAG, and CO(2) + Er:YAG lasers may be used safely in nerve tissue surgery.

Effect of platelet glycoprotein IIb/IIIa receptor antagonist on survival of epigastric island flaps in rats with total venous occlusions.

We evaluated the effect of tirofiban hydrochloride on the survival of epigastric island flaps in rats that had had all the veins occluded. Male Wistar Albino rats were randomly assigned to control (treated with sterile saline) and experimental (treated with tirofiban hydrochloride 1 mg/kg intravenously) groups. An epigastric island skin flap 3x6 cm was raised in each rat. All veins that drained the flap were ligated to give total venous occlusion. Blood flow was recorded by laser Doppler preoperatively (baseline), immediately after the flap had been sutured back to its original position (acute) and on postoperative days 1 and 3. The degree of necrosis was evaluated on day 3. Mean percentage necrosis and minimum laser Doppler values were compared in the two groups. Total necrosis was evident on day 1 in the control group and on day 3 in the experimental group. Macroscopic evidence was confirmed by histopathological examination. There were appreciable differences in blood flow and in the necrotic area of the flap in the experimental group compared with the control group on both days 1 and 3. Tirofiban hydrochloride might be effective in this flap model.

Effects of clopidogrel on survival of rat skin flaps.

Clopidogrel is a thienopyridine derivative that is chemically related to ticlopidine, which irreversibly inhibits platelet aggregation by selectively binding to adenylate cyclase-coupled adenosine diphosphate receptors on the platelet's surface. In animal models, clopidogrel has been shown to reduce the incidence of both arterial and venous thrombi. In the present study the effects of clopidogrel on the survival of rat epigastric island flaps was researched. Epigastric island flaps of 7x7cm were raised from symphisis pubis to arcus costa with the panniculus carnosus. The experimental group received seven doses of 25mg/kg clopidogrel postoperatively, the first dose given immediately after the suturing of the flaps. The rats were anaesthetised on postoperative day 7 to assess the survival of flaps. The difference between the clopidogrel and the control group was significant (P<0.005). The full-thickness skin samples obtained after the calculation of survival percentages revealed thinning of the epidermis layer and active chronic inflammation in both groups. However, diffuse dilated vessels, extravasated eritrocytes were seen in the clopidogrel group flaps. The results indicated a significant increase in flap survival in rats given clopidogrel. Further research is needed to assess the critical doses of clopidogrel to create optimal flap survival improvement.

[Three-dimensional orthotopic tissue reconstruction with a free, prefabricated high-density porous polyethylene implant flap]. / Serbest prefabrike poröz polietilen implant flebi ile ortotopik üç boyutlu doku rekonstrüksiyonu modeli.

BACKGROUND: We investigated the appropriateness of the implant to be used in free-tissue transfers in a rabbit model in which a full-thickness skin graft was wrapped around a prefabricated high-density porous polyethylene implant. METHODS: In ten New Zealand white rabbits, high-density porous polyethylene implants (Medpor), 10x15x3 mm in size, were bilaterally placed and anchored underneath the superficial inferior epigastric artery and vein pedicle under anesthesia. The flaps were prefabricated through vascular induction. Eight weeks later, the flaps were wrapped by a full-thickness postauricular skin graft, following orthotopic transplantation. Two weeks after grafting, full-thickness biopsy samples were obtained from the distal one-third of the implants and stained with hematoxylin-eosin and Masson trichrome for histologic examination. RESULTS: Graft compliance was observed in all the implants. Histologic sections showed rich fibro-neovascular tissue, neovascularization, and development of connective tissue cells. There were very few polymorphonuclear cells. No signs of inflammation were observed. CONCLUSION: Prefabrication of the high-density porous polyethylene implant under the superficial inferior epigastric artery and vein results in sufficient conditions for its use in free transfers.

Hatchet-shaped tensor fascia lata musculocutaneous flap for the coverage of trochanteric pressure sores: a new modification.

The tensor fascia lata flap is one of the appropriate choices for the coverage of trochanteric pressure sores. The authors designed a new, hatched-shaped tensor fascia lata musculocutaneous flap with distal Z-plasty closure and applied it to four trochanteric defects in 4 patients. Satisfactory results were obtained in all patients. The hatchet-shaped tensor fascia lata musculocutaneous flap is very safe, reliable, and practical. Designing the flap in a hatchet shape allows one to use the proximal and well-vascularized portion of the flap in the trochanteric pressure sore area. Another important advantage is the possibility of reuse resulting from recurrence. Prevention of a "dog-ear" deformity at the recipient site provides a smooth contour on the lateral aspect of the thigh. Another advantage is the tension-free Z-plasty closure of the donor site without need of grafting.