Comparison of surgical techniques used for prevention of neuroma in order to make more clear the role of the epineurium. An experimental study.

AIM: Several studies have been conducted for the prevention of neuroma and recently published experimental studies include interventions on epineurium. The techniques which include interventions on epinerium were compared to reveal the role of epinurium in neuroma prevention. MATERIAL E METHODS: 55 Sprague-Dawley rats were divided into five groups. Two of the groups were negative and positive controls. The proximal nerve stump was left "free" in the negative control group, while the stump was implanted in a muscle pocket in the positive control group following sciatic nerve transection. Experimental groups include epineural ligation, epineural stripping and epineural capping procedures. Follow-up period was six months. After sacrification of the rats, histopathologic and immunohistochemical examinations were conducted as well as real-time PCR studies for the assessment. Statistical analysis was performed. RESULTS: The most prominent neuroma formation was detected in the epineural capping group, while the least neuroma was observed in the epineural ligation group. DISCUSSION: Statistically significant differences were obtained when the three experimental groups were compared with both control groups. Interestingly there was no significant difference in-between the control groups in terms of preventing neuroma formation. CONCLUSION: epineural ligation group were found to be superior to both control groups as well as experimental groups. Use of epineural capping was concluded to increase the formation of neuroma rather than preventing. Intramuscular implantation of nerve stump had no preventive effect on neuroma formation. KEY WORDS: Capping, Epineurium, Ligation, Neuroma, Stripping.

Single-session repair of multiple pressure ulcers in non-ambulatory patients.

OBJECTIVE: Pressure ulcers (PUs) are highly prevalent and challenging wounds. In this study, patients with either tetraplegia or paraplegia, all of whom had multiple grade 4 PUs and who underwent single-session surgical treatment were included. In order to increase the mobility of the musculocutaneous flap, the gluteus maximus muscle, which cannot be used by immobile patients, was detached and inserted into the flap. METHOD: This was a retrospective case series and all PUs were reconstructed within the same surgical session. RESULTS: A total of nine patients participated in the study, all of whom were male. Mean age was 33 years (range: 20-42 years). Mean follow-up period was 14.3 months (range: 9-24 months). All patients had a successful single-session repair of all PUs. Total or partial flap losses were not observed. Mean and total number of reconstructed PUs were 2.55 and 23, respectively. The mean area of reconstructed open wounds per patient was 174.6cm2 and the mean operation duration was 253 minutes. The level of blood loss was acceptable as the decrease in haemoglobin levels was not more than 2g/dl for each patient. CONCLUSION: Multiple PUs can be repaired in one session using gluteus maximus musculocutaneous flaps in immobile patients. Based on the fact that the gluteus maximus is an essential muscle for ambulation, our approach can only be used in the treatment of patients with irreversible paraplegia or tetraplegia. When all prerequsities are met, the amount of blood loss and operation duration are acceptable, and returning the patient to a wound-free state can be achieved more quickly compared to multi-session repairs. Air-fluidised beds are vital tools for accomplishing single session repairs of multiple PUs. The data shows that the approach is safe and can be used in patients with multiple PUs.

Comparison of surgical techniques used for prevention of neuroma in order to make more clear of the role of the epineurium: an experimental study.

AIM: Several studies have been conducted for the prevention of neuroma and recently published experimental studies include interventions on epineurium. The techniques which include interventions on epinerium were compared to reveal the role of epinurium in neuroma prevention. MATERIAL E METHODS: 55 Sprague-Dawley rats were divided into five groups. Two of the groups were negative and positive controls. The proximal nerve stump was left "free" in the negative control group, while the stump was implanted in a muscle pocket in the positive control group following sciatic nerve transection. Experimental groups include epineural ligation, epineural stripping and epineural capping procedures. Follow-up period was six months. After sacrification of the rats, histopathologic and immunohistochemical examinations were conducted as well as real-time PCR studies for the assessment. Statistical analysis was performed. RESULTS: The most prominent neuroma formation was detected in the epineural capping group, while the least neuroma was observed in the epineural ligation group. DISCUSSION: Statistically significant differences were obtained when the three experimental groups were compared with both control groups. Interestingly there was no significant difference in-between the control groups in terms of preventing neuroma formation. CONCLUSION: epineural ligation group were found to be superior to both control groups as well as experimental groups. Use of epineural capping was concluded to increase the formation of neuroma rather than preventing. Intramuscular implantation of nerve stump had no preventive effect on neuroma formation. KEY WORDS: Capping, Epineurium, Ligation, Neuroma, Stripping.

A New Technique in Correction of Nipple Inversion Using Dermal C Flaps.

BACKGROUND: Nipple inversion, which is defined as a nipple located on a plane deeper than the areola, presents both functional and cosmetic problems. Surgical repair of severe cases involves suture or flap techniques. In the present study, an alternative repair technique using two cross dermal areolar flaps to correct challenging inverted nipples is presented. Releasing the inverted nipple is performed by severing the underlying tight fibrous tissue bands and canaliculi. METHODS: This is a retrospective case series. Fifteen patients who had been operated between January 2010 and January 2016 were included in the study. Seven of these had bilateral inverted nipples. Patient age at operation ranged from 26 to 47 years (mean age, 32.5 years). All nipples were congenital, with no previous operations. The follow-up period ranged between 8 and 16 months (mean of 13 months). RESULTS: There were no complications associated with surgery, including infection, hematoma, permanent sensory disturbance, or nipple necrosis. Unilateral recurrence occurred in one patient on the 26th postoperative day. This patient was reoperated on successfully using the same method. Adequate projection was achieved in all patients. All patients were satisfied with their results. CONCLUSIONS: The authors conclude that their procedure is a reliable, simple, safe, and effective method for correction of inverted nipples. The alignment of the scar with the junction of the nipple and the areola leads to a more aesthetic appearance with no apparent scarring. This technique can be applied to any type of inverted nipple as a primary surgical procedure. LEVEL OF EVIDENCE IV: 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 different option in vascular bone grafts in the hand and wrist region: Use of a dorsoulnar artery-based osteo-fascio-cutaneous flap: A case series.

OBJECTIVES: This study aims to describe our surgery technique and discuss patients treated through the dorsoulnar artery (DUA)-based technique of osseous and osteo-fascio-cutaneous vascularized ulnar bone grafting. PATIENTS AND METHODS: Between January 2011 and January 2015, six male patients (median age: 22.5 years; range, 20 to 24 years) who underwent surgery during which the technique of DUA ulnar bone graft was utilized. One patient with scaphoid nonunion, three patients with Kienböck's disease, and two patients with a traumatic metacarpal defect were retrospectively evaluated. The joint range of motion (ROM), grip strength, Disabilities of the arm, shoulder and Hand (DASH) questionnaire score and Visual Analog Scale (VAS) score, and radiographies before and after surgery were examined. Scintigraphy was performed at 12 weeks postoperatively to monitor the viability of the bone graft. RESULTS: All patients showed improvements in the ROM, grip strength, VAS, and DASH scores. According to the radiographic examination, bone union was achieved in all patients and the scintigraphy revealed that vascularization was detected in the bone tissue. CONCLUSION: The advantages of DUA-based vascularized bone graft are good bone quality and quantity and versatility due to its long pedicle. The osteo-fasio-cutaneous DUA flap seems to be effective in the treatment of traumatic metacarpal bone defects accompanied by skin loss. The DUA-based vascularized ulnar bone may be a source for scaphoid and lunate biological bone reconstruction.

Does videoendoscopy provide three-dimensional vision in closed rhinoplasty?

Rhinoplasty is a common procedure in cosmetic surgery all over the world. Patients desire enhancement of their facial beauty by the correction of preexisting nasal deformities. Precisely performed operations lead to better results, and enhancing technical accuracy accordingly results in more successful outcomes. Endoscopy helps us visualize the closed parts of the body with the aid of an illuminated optical device. The objective behind the present case series was to bring the advantages of open and closed rhinoplasty together by using endoscopic vision systems. A total of 312 patients with unoperated nasal deformities from private practice were operated, and videoendoscopic closed rhinoplasty was performed on each patient. Postoperative patient satisfaction was assessed using the Rhinoplasty Outcome Score; the level of satisfaction was found to be excellent. In the present case series, it was hypothesized that trocar mobility under the skin flap allows virtual binocular vision that eventually leads to stereoptic depth perception. This allows virtual three-dimensional (3D) vision on the screen of the endoscope with a regular trocar. The mobility of the tip in the transverse axis created a virtual 3D appearance. Our experiences with videoendoscopic closed rhinoplasty are shared in this report.

Useful Method for Intraoperative Monitoring of Facial Nerve in a Scarred Bed.

Facial nerve is the main cranial nerve for the innervation of facial expression muscles. Main trunk of facial nerve passes approximately 1 to 2 cm deep to tragal pointer. In some patients, where a patient has multiple operations, fibrosis due to previous operations may change the natural anatomy and direction of the branches of facial nerve. A 22-year-old male patient had 2 operations for mandibular reconstruction after gunshot wound. During the second operation, there was a possible injury to the marginal mandibular nerve and a nerve stimulator was used intraoperatively to monitor the nerve at the tragal pointer because the excitability of the distal segments remains intact for 24 to 48 hours after nerve injuries. Thus, using a nerve stimulator at the operational site may lead to false-positive muscle movements in case of injuries. Using the nerve stimulator to stimulate the main trunk at the tragal point may help to distinguish the presence of possible injuries. A reliable method for intraoperative facial nerve monitoring in a scarred operational site was introduced in this letter.

Is It Possible to Increase Flap Viability by Hydrostatic Dilation?: An Experimental Study in the Rat Abdominal Fasciocutaneous Flap Model.

INTRODUCTION: Ergun et al previously demonstrated the efficacy of hydrostatic dilation in a TRAM flap model in an experimental study. We investigated the effect of hydrostatic dilation on a fasciocutaneous flap model. METHODS: Eighteen female Wistar rats were equally divided into 3 groups, of which 1 served as a control. In the second, the abdominal fasciocutaneous flap surgical delay procedure was performed by division of the left superficial inferior epigastric (SIE) vessels. In the third, hydrostatic dilation was performed on the left SIE artery and vein, with a mean pressure of 300 mm Hg, while elevating the flap on the right-sided SIE pedicle. The groups were compared by microangiography and by the survival ratio of abdominal flaps 7 days after elevation. RESULTS: The mean (SD) flap necrosis rates were as follows: control group, 44.75% (4.31%); delay group, 33.32% (7.11%); and hydrostatic dilation group, 32.51% (5.03%). There was a significant difference between the control group and the other 2 groups (P < 0.05). There was no difference between the delay and hydrostatic dilation groups with respect to surface area necrosis. The microangiographies showed remarkable increased vascularity in the delay and hydrostatic dilation groups. CONCLUSIONS: Hydrostatic dilation is a new method of enhancing flap viability that could be used in clinical cases in place of surgical delay once further studies and clinical trials are completed.

Mandibular reconstruction after hemimandibulectomy.

Ameloblastoma is a benign tumor of the mandible, which is not commonly diagnosed in the early stages. The extensive mandible resection may be needed for treatment. In this report, we present 6-year follow-up results of a patient who had undergone hemimandibulectomy and mandible reconstruction with free vascularized fibular flap, costochondral rib graft to restoration of the temporomandibular joint, and iliac bone graft to enhance the vertical height of the mandible. The long-term results are very satisfactory.