A Single Superior Gluteal Artery Perforator Flap in Reconstruction of Large Midline Sacral Defects: A Method for Practical Harvest and Safe Closure.

BACKGROUND: Large midline sacral defects are reconstructive challenges. Superior gluteal artery perforator (SGAP) flap provides enough tissue and versatility to cover large defects; however, a single flap may be insufficient. We present a technique to cover large defects using single SGAP flaps. METHODS: Large sacral defects (>100 cm2) reconstructed with single SGAP flaps were included. Angle of transposition (45°-60°) was determined based on the tissue laxity and mobility of gluteal area. Perforator identification, intramuscular dissection, or skeletonization was not performed. Outcomes were measured as achieving durable reconstruction, flap viability, and complications. RESULTS: There were 17 patients (12 male, 5 females; aged 25-72 years) with different etiologies. The mean flap surface area (136.1 ± 45.6 cm2, between 9 × 8 and 26 × 10 cm) was smaller than the mean defect surface area (211.1 ± 87.2 cm2, between 10 × 10 and 28 × 14 cm) (P < 0.001). All flaps survived with no partial or complete flap loss. Minor dehiscence in 4 patients (2 at donor site and 2 at recipient site) healed with dressing changes or using negative-pressure vacuum therapy. All patients had durable outcomes without any recurrence. CONCLUSION: Single unilateral SGAP flaps can be used to completely cover midline large sacral defects. It is important to design the flaps to have a joint side with the defect in the proximal part and use the intrinsic mobility of gluteal soft tissues for the closure. Flaps can be (1) planned to be smaller than the defects, (2) harvested with no intramuscular perforator dissection or pedicle skeletonization, and (3) transposed with an angle less than 60°.

Comparison of the Effect of Spreader and T-Splay Graft in Internal Nasal Valve Management.

BACKGROUND: The midvalve area is one of the most important anatomical points in rhinoplasty procedures. An additional intervention may be required to ensure there is no narrowing in this region. For this reason, several different techniques are used. Spreader graft technique is the most common of all these methods. T-splay graft technique is an alternative method that can effectively widen the angle of the midvalve. The present study compares the anatomical and functional outcomes of these two methods. METHODS: The study included 60 cases who presented to our clinic for rhinoplasty. The cases were evaluated demographically, anatomically, and functionally, and the acquired data were recorded. All cases were preoperatively administered the Visual Analogue Scale, the Nasal Obstruction Symptom Evaluation scale, and the modified Glatzel mirror test. By randomly selecting the cases, midvalve restoration was performed with a spreader graft in 30 cases and a T-splay graft in 30 cases. RESULTS: A comparison of the Visual Analogue Scale, the Nasal Obstruction Symptom Evaluation scale, and the modified Glatzel mirror test scores revealed that the scores of both groups at postoperative months 3 and 6 were significantly different from the preoperative measurement values. CONCLUSIONS: Although spreader graft technique is a very effective method in midvalve management, we believe that T-splay graft technique may also produce effective outcomes. In addition, the midvalve functions could be better simulated anatomically and functionally with T-splay graft technique. Therefore, we believe that T-splay graft technique is an alternative method that can be safely used in selected cases. LEVEL OF EVIDENCE III: 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 .

Scalp Micropigmentation Procedure: A Useful Procedure for Hair Restoration.

ABSTRACT: Medical tattooing of the skin to camouflage scars or to mimic hair or nipple/areola regions has gained popularity in Aesthetic Surgery and Dermatology clinics. The SMP procedure was used in 22 patients to correct scalp pigmentary problems between 2017 and 2020. The study included 16 men and 6 women; all female subjects had female pattern hair loss, while one of them also had alopecia areata. There were 10 male patients with male pattern hair loss and 6 of them were corrected using micropigmentation. The rest were subjected to an adjunctive procedure for hair transplantation. There were six male patients that had scalp scars. All patients had three micropigmentation sessions weekly and a fourth touchup procedure that was included one month after the last session. The follow-up period ranged from 7 to 32 months with a mean of 20 months. The amount of fading observed after the follow-up was minimal. There was an allergic reaction in just one patient following the procedure. There were no serious adverse effects or complications due to the procedure. The questionnaire the authors sent the patients at least six months following the procedure showed 80% of the patients (100% of the women) were very satisfied with the result and 100% of the patients would recommend the procedure to others with similar problems. SMP appears to be good solution for patients who don't want the hair transplantation or who underwent previous hair transplantation surgeries with unsatisfactory results. Also, SMP can be used to camouflage any type of scalp scars.

Metatarsal artery perforator-based propeller flap.

Soft-tissue defects of the distal foot that involve an exposed tendon and bone demonstrate a reconstructive challenge for plastic surgeons. This report investigates the feasibility and reliability of metatarsal artery perforator (MAP)-based propeller flap for reconstruction of the distal foot soft-tissue defects. Between July 2011 and June 2012, six patients underwent distal foot reconstruction with seven MAP-based propeller flaps. Five flaps were based on the third metatarsal artery and two flaps were based on the first metatarsal artery. The flap size ranged from 4 × 2 cm to 8 × 4 cm. All flaps completely survived. Two patients developed transient distal venous congestion, which subsided spontaneously without complications. There were no donor site complications. All patients were ambulating without difficulty within the first month of surgery. MAP-based propeller flaps can be used to repair the distal foot soft-tissue defects, providing sufficient skin territory and excellent esthetic and functional recovery.

Reconstruction of lateral lower lip defects with transverse lip advancement flap.

BACKGROUND: Lower lip defects between one and two thirds of the lower lip are usually reconstructed with neighboring tissues from the upper lip, cheeks, or the mentum or a combination of these tissues. In this article, we offer a simple and effective reconstruction option that can be used for lateral defects between one third and two thirds of lower lip tissue. Utilizing the tremendous flexibility and expandability of the lip tissue, we tried to minimize the incisions and scar, and maximize the sensation and function with transverse advancement flap. PATIENTS AND METHODS: Ten patients with lateral lower lip defects, after tumor ablation, were treated by this technique. After excision of tumor, the existing incision is extended to medial by following the natural labiomental crease. Full-thickness incision is ended at the level of commissure not to disturb the buccal and marginal mandibular branches of the facial nerve. Intraoral incision is made 1 cm above the gingivobuccal sulcus .The mental nerve was dissected and preserved to keep the sensorial innervation of the lower lip. Thus, transverse advancement labial flap that includes the orbicularis oris with intact neurovascular supply is freed to provide the desired advancement. RESULTS: Satisfactory functional, aesthetical, and sensational results were obtained. CONCLUSION: A dynamic reconstruction can be provided with superior results in terms of lip appearance and function with transverse lip advancement flap. In planning a lip reconstruction, we think that transverse lip advancement flap should be considered as a second ladder after primary closure.

Treatment of a supernumerary large breast with medial pedicle reduction mammaplasty.

UNLABELLED: Accessory breast tissues including nipples, areolas, and glandular tissue may develop on the chest in addition to two normal breasts. An accessory breast with a complete ductal system, areola, and nipple is termed a "supernumerary breast." Supernumerary nipples are fairly common, but complete supernumerary breasts are rare. This report describes an 18-year-old woman who presented with a complete supernumerary breast including a nipple-areola complex located on the upper outer quadrant of her left breast and causing severe breast asymmetry. She was referred to the authors for aesthetic reasons. Unilateral reduction mammaplasty was performed to remove the supernumerary breast and correct the breast asymmetry. The medial pedicle Wise technique was used for en bloc resection of the ectopic breast, including the nipple-areola complex together with the upper outer breast quadrant. The woman's postoperative course was uneventful. At 8 months after surgery, she was very satisfied with the results. Ectopic breast tissue can be treated by a variety of methods such as liposuction or excision. However, breast deformation because of a complete supernumerary breast is very rare, and research on the treatment of such patients is lacking. No reports describing surgical treatment for this condition were identified in the literature. The authors suggest that unilateral breast reduction is the most appropriate treatment, allowing excision of the accessory tissues, with the best possible cosmetic outcome. LEVEL OF EVIDENCE V: 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 .

Comparison of two different vascular delay methods in a rat cranial epigastric perforator flap model.

The effectiveness of vascular delay in transverse rectus abdominis muscle flaps has been demonstrated in many studies. In deep inferior epigastric perforator flaps, however, the effectiveness of ligation of deep versus superficial epigastric vessels in producing delay is unclear. Using a rat model, we compared ligation of deep and superficial vessels with each other and with a (nondelayed) control group (n = 10). One vascular delay group (n = 10) had ligation of the contralateral cranial epigastric vessels (homolog to the human deep inferior epigastric vessels); the other (n = 10) had ligation of contralateral superficial inferior epigastric vessels. One week later, cranial epigastric perforator flap elevation was performed. Both vascular techniques were effective in producing delay, and there was no statistically significant difference between the 2 groups. Ligation of superficial inferior epigastric vessels, deep inferior epigastric vessels, or both, at least 1 week prior to the deep inferior epigastric perforator flap elevation may increase the usable skin paddle area in humans.

Correction of major saddle nose deformities with nasomaxillary depression using an intraoral and external open rhinoplasty approach.

Nasomaxillary depression, which may be seen with major saddle nose deformities, especially as a sequel to childhood nasal trauma, generally is overlooked during management of the saddle nose. To handle both the saddle nose deformity and nasomaxillary depression, the authors used a one-stage intraoral and external open rhinoplasty approach for 12 patients. Lateral nasal osteotomies and correction of midface retrusion with crescent-shaped autogenous rib cartilage grafts were performed through two bilateral intraoral gingivobuccal incisions. The external open rhinoplasty approach was used for the correction of the saddle nose deformities. The mean follow-up period after the surgery was 2 years (range, 1-3.5 years). The correction of nasal tip depression resulting from midface retrusion was evaluated by lateral cephalometric radiographs. The mean movement of the nasal tip anteriorly in the sagittal plane 1 year after the operation was 5.5 mm (range, 4-7 mm). The functional and aesthetic results were satisfactory for all the patients. As the findings show, the intraoral part of the approach provides a route for the placement of cartilage grafts to correct the depressed nasal tip, augment the paranasal area, and provide support to the lateral alar bases and the controlled low-to-low lateral osteotomies. The external part of the approach provides correction of the saddle nose deformity.

The radix nasi island flap: a versatile musculocutaneous flap for defects of the eyelids, nose, and malar region.

A versatile musculocutan flap from the radix nasi region, the radix nasi island flap, is described. The flap has an axial blood supply derived from the dorsal nasal branch of the ophthalmic artery which is anastomosed to the terminal branch of the facial artery. The flap includes the skin, subcutaneous tissue, and procerus muscle. Ten patients, aged 50 to 86 years, have been reconstructed with this flap for defects in the nose (in 4 cases), midface (in 4 cases) and lower eyelids (in 2 cases). The mean flap size was 17 x 23 mm (range: 15 x 20 to 20 x 27 mm). All flaps fully survived. Additional complications and morbidity were not observed. The donor sites were closed a primarily closure in all cases. Follow-up ranged from 3 to 12 months (mean: 8.2 months). The radix nasi flap is a safe flap, has minimal donor site morbidity, and is especially suited for nasal and midface reconstruction in terms of attaining a suitable color and thickness.

Intranasal porous polyethylene implant extrusion 7 years after insertion in a patient with Hashimoto disease.

We report a case of intranasal porous polyethylene implant extrusion 7 years after insertion in a patient with Hashimoto disease. We also discuss the possible causes of the extrusion and convey the histopathologic examination and microbiological investigation results of the samples taken from the removed implant.

Correction of septal and midface hypoplasia in maxillonasal dysplasia (Binder's syndrome) using high-density porous polyethylene.

BACKGROUND: Maxillonasal dysplasia (Binder's syndrome) is a congenital malformation characterized by an extremely flat and retruded nose. METHODS: This report describes an 18-year-old woman with maxillonasal dysplasia (Binder's syndrome). The septal deficiencies and maxillary retrusion of the patient were corrected by using an L-shaped implant and a crescent-shaped high-density porous polyethylene implant through the oral vestibular sulcus via an external rhinoplasty approach. RESULTS: After the operation, the tip of the nose had moved 5.5 mm anteriorly in the sagittal plane and 11.9 mm coronally in the vertical plane. Also, the nasolabial angle had increased after the surgery. Follow-up evaluation at 24 months showed good correction of the nasal and midface projection. CONCLUSIONS: High-density porous polyethylene implants are a good alternative for patients with Binder's syndrome, especially those who will not accept costal cartilage grafts or orthognathic surgery and who have tendency for hypertrophic scarring.

"Reading man flap" design for reconstruction of circular infraorbital and malar skin defects.

BACKGROUND: Surgical complications such as lid retraction and ectropion from graft or flap scar contracture make reconstruction of skin defects in the malar and infraorbital regions challenging. OBJECTIVE: A new flap design, the reading man flap, was used to overcome these problems. The Limberg and bilobed flap were compared with the reading man flap. METHODS: The reading man flap consists mainly of a superiorly based quadrangular flap and an inferiorly based triangular flap. Malar and infraorbital circular skin defects measuring 14 x 14 to 40 x 40 mm were reconstructed with a reading man flap in 13 patients. The defects occurred after basal cell carcinoma in all patients. The Limberg flap, bilobed flap, and reading man flap were planned for same-sized defects on the abdominoplasty resection material. The results were compared in terms of total scar area, scar length, and total healthy skin area discarded. RESULTS: When comparing the 3 flap designs, the reading man flap was the most suitable flap in terms of total scar area and length. CONCLUSION: The reading man flap can be used to reconstruct malar and infraorbital circular defects with good cosmetic results and without creating any tractional forces to the eyelids.

Necrotizing fasciitis of the chest wall with a retropharyngeal abscess: case report and literature review.

We herein report a case of a diabetic 49-year-old woman with anterior chest wall necrotizing fasciitis that caused a retropharyngeal abscess and discuss the literature surrounding necrotizing soft tissue infections of the chest wall. The patient was treated with serial wound debridements, antibiotic therapy, and percutaneous drainage and serial irrigation of the retropharyngeal abscess with a silicone catheter. The resulting defect was grafted with a split thickness skin graft.

Simplified and versatile use of gluteal perforator flaps for pressure sores.

As a first choice for treating pressure sores, we present our experiences with gluteal perforator flaps and a simplified surgical technique. Twenty-three gluteal perforator flaps were used in 20 patients (13 males, 7 females; aged, 8-68 years) with pressure sores. The pressure sores were sacral in 16 patients, ischial in 2, and trochanteric in 2 patients. During follow-up, recurrence in the same region did not occur. Our simplified operative technique includes finding a suitable perforator with a Doppler probe (it does not matter from which mother artery), outlining the flap, dissecting the perforator with just enough length, and transposing the flap to the defect. The gluteal region has numerous perforators, and there is no need to depend on strict anatomic landmarks to detect perforator vessels or to sacrifice main arteries, as has been the case when raising gluteal perforator flaps.

Malignant eccrine spiradenoma of the scalp.

Malignant eccrine spiradenoma is a rare neoplasm generally arising from long-standing benign eccrine spiradenomas; it is rarely seen on the scalp. A 27-year-old woman with a malignant eccrine spiradenoma of the scalp, which had occurred 8 months after the inadequate excision of a benign eccrine spiradenoma, was treated at our hospital. The patient underwent lymphoscintigraphy. A biopsy of the sentinel lymph nodes in the right periparotid and left occipital regions was performed, and the nodes showed no metastases. The tumor with its large subcutaneous extension and the outer table of the cranium were removed. A split-thickness skin graft was applied on the exposed inner table. At 24 months' follow-up, there has been no tumor recurrence. We report a case of a malignant eccrine spiradenoma of the scalp with cranial involvement that arose from an inadequately removed, long-standing, benign eccrine spiradenoma in a young patient. Also, we review the existing literature on malignant eccrine spiradenoma of the scalp.

7-plasty technique for the surgical treatment of congenital longitudinal ear lobe cleft.

The ear lobe plays an important part in the aesthetic appearance of the auricle. The clefts of the ear lobe may vary in a wide range of severity from a simple notching to extensive tissue deficiency. We have operated on a congenital longitudinal ear lobe cleft using an alternative surgical method and obtained a favorable result. This method consists of a 7-plasty (or inverted L-plasty) that was performed to correct the deformity. The inner edges of the lobes were excised, and a medial extension incision was added. This helped to drop the medial part inferiorly like a back-cut so that the length of that lobe was increased. Eversion of the lateral lobe was also done, and the edges were approximated so that the angle between the extension incision and the excision line was increased to produce an obtuse angle between the 2 lines. We report an alternative method of reconstruction that can be used in longitudinal ear lobe clefts that offers a favorable result.

Median cleft of the lower lip: report of two new cases and review of the literature.

Median clefts of the lower lip and mandible are rare craniofacial clefts. Couronné in 1819 was the first to describe the condition. The midline cleft of the lower lip was classified by Tessier as a type 30 craniofacial cleft. Recently, the total number of the reported cases had increased to about 66 in the world literature. In addition, 2 more patients are presented here. The first case involves only a small notch in the vermilion; the deformity was treated by Z-plasty. In the second case, a midline incomplete cleft of the lower lip, a sublingual abnormal frenulum, a complete cleft in the mandible, a bifid sternum, a presternal skin tag, and a ventricular septal defect in the heart were present. At operation, Z-plasty of the lingual frenulum released the normal-sized tongue. The lip cleft was corrected by a simple V excision followed by closure in 3 layers. The mandibular segments were "vitalized" with a bone rongeur and immobilized in the predetermined position with an interosseous stainless steel wire. Because the bone fusion was complete, the stainless steel wire was taken out after 3 months so that it would not prevent mandibular development. Our treatment methods and others are discussed.

An effective antioxidant drug on prevention of the necrosis of zone of stasis: N-acetylcysteine.

The zone of stasis, the encircling area of the zone of coagulation, is a critical area which determines the depth and width of the necrosis in burns. Many agents were proposed to salvage the zone of stasis. Due to the known preventive and therapeutic effects of N-acetylcysteine on hepatotoxicity, nephrotoxicity, pulmonary injury, and multiple organ failure in humans, the effect of N-acetylcysteine on saving the zone of stasis was investigated in this experimental study. The effects of N-acetylcysteine administration via oral or intraperitoneal route was compared in a rat comb-burn model. The extent of burn wounds was evaluated by photography and planimetry in the groups. Additionally, skin samples were obtained to analyze malondialdehyde levels to see the antioxidant effect of N-acetylcysteine. In control group (no treatment), the burn areas went to near total necrosis. In intraperitoneal and oral treatment groups, skin survival occurred in the interspace area of the comb. There was no difference between the groups in terms of MDA concentrations. In conclusion, this study showed us the possible saving effect of N-acetylcysteine on the zone of stasis. N-acetylcysteine may be used in the cases of severe burns, not only for its effects on wound healing but also the systemic effects of the drug.

Rehabilitation of a malocclusion with an onlay removable partial denture in a patient with ankylosing spondylitis: a case report.

This case report describes the prosthetic rehabilitation of a patient with ankylosing spondylitis who presented with a malocclusion due to the unfavorable reduction of a mandibular fracture following a traffic accident. The residual malocclusion was successfully corrected with a maxillary removable partial denture and a mandibular onlay removable partial denture.