Auriculotemporal Carcinoma - A Retrospective Case Series.

Rationale: Eleven cases with auriculotemporal cancer were reviewed for prognostic analysis. Patient Concerns: Follow-up ranged from 1.2 to 12 years (median 5.01 years). Diagnosis Treatment and Outcome: Three patients with parotid gland carcinoma, out of those, two had chemoradiotherapy, died in the first 2 years of treatment. They were at stage T4 and tumour progressed with distant metastasis. Otorrhoea was the most common symptom in patients with primary temporal bone carcinoma. One patient with auricular carcinoma had a recurrence at the primary site 13 months after surgery. One patient with T1, two patients with T2 and one patient with T3 have completed a 5-year survival period. One patient with T1 and another one with T2 are still at a 2-year follow-up period with no recurrence. Take-Away Lessons: Complete resection is the treatment of choice. Post-operative radiotherapy is highly recommended. The most decisive prognostic indicator is the advanced stage. Early diagnosis has great importance.

Pre-expanded pedicled thoracodorsal artery perforator flap for postburn axillary contracture reconstruction.

INTRODUCTION: The axillary region is one of the sites most frequently affected by postburn contractures. In this clinical study, we used pre-expanded pedicled thoracodorsal artery (TDA) perforator flaps for release of postburn contracture of the axillary region. PATIENT AND METHODS: Five patients with severe axillary burn contractures were reconstructed with six pre-expanded pedicled TDA perforator flaps between 2008 and 2010. All were men ranging in age from 20 to 26 years (mean, 22 years). Mean time of follow-up was 12 months. Flap and donor site complications, preoperative, and postoperative range of motion of axillary joint were evaluated. RESULTS: All flaps survived without significant complications. Partial flap necrosis was seen in only one flap. Minimal transient venous congestion occurred in one flap during the early postoperative period. A complete range of motion at the axillary joint was achieved in all patients by the end of the reconstruction period. The donor sites were closed primarily with linear scars in all cases. CONCLUSION: The pre-expanded pedicled TDA perforator flap is a suitable alternative for coverage of the axillary defects after the release of the burn contractures. A pliable texture and large size flap can be obtained to transfer to the axillary area and the donor site scar is considered as cosmetically acceptable.

Should we hesitate to use subcutaneous tunneling for fear of damaging the sural flap pedicle?

BACKGROUND: The distally based sural nerve flap is a preferable option for covering defects of the lower third of the leg. However, many authors noted that in particular pressure exerted by tunneling of the flap pedicle could be harmful. Thus, they either inset the pedicle or exteriorize the pedicle to decrease complications. METHODS: We used distally based superficial sural artery island flaps for the reconstruction of defects of the lower leg, the ankle, and malleolus in 12 patients between 2004 and 2008 without tunelization. The defects were covered with no major complications. RESULTS: In 3 flaps, there was a small amount of distal marginal necrosis, which was excised and closed spontaneously or skin grafted. CONCLUSION: We concluded that unless there are certain risk factors such as arterial hypertension, diabetes, peripheral vascular disease, and vasculitis, avoiding a subcutaneous tunneling is not necessary.

Reconstruction of distal forefoot burn defect with retrograde medial plantar flap.

Burn reconstruction of forefoot remains as a difficult challenge, because the local flap alternatives are limited. We evaluated the efficiency of distally based medial plantar fasciocutaneous island flap in the coverage of forefoot defects resulting from release of toe contracture and burn debridement. Four patients with toe contractures and two patients with third degree burn in forefoot were treated between June 2004 and February 2006. The mean follow-up period was 10.4 months. The flaps were elevated as with a fasciocutaneous base on the distal medial plantar artery. The dimensions of the flaps ranged from 4cmx3cm to 5cmx4cm. The skin over the pedicle was included as a part of flap in three cases. Concomitant vein of the pedicle was anastomosed with the first plantar digital vein in four cases. In the early postoperative period, one flap used to cover third degree burn due to high-voltage electric injury was lost completely. We concluded that this flap was an appropriate alternative reconstructive option for the forefoot defect. Including skin and subcutaneous tissue over the pedicle to flap protects the pedicle against kinking and compression. Venous supercharging of the flap improves venous drainage.

Chronic postburn palmar contractures reconstruction using the medial pedis perforator flap.

Chronic flexion contractures of the palm of the hand impair hand function considerably and cause a poor esthetic appearance. Various reconstructive methods have been used for the treatment. However, satisfactory esthetic and functional results are difficult to achieve due to the unique anatomic characteristics of the palmar region, such as thick, cornified, stratified squamous epithelium. In the present study, free medialis pedis flap was used in a number of patients who suffered from severe palmar flexion contractures due to burn injuries. Here, the experience, technique, and follow-up results are presented. Eleven patients admitting to our department with palmar flexion contracture were reconstructed with free medialis pedis flap from 2004 to 2007. All were men and ranged in age from 19 to 22 years old (average, 21 years). In all cases, different parts of palmar region were covered. In all cases except 2, arterial anastomosis was done to proper digital arteries. Although the concomitant vein and superficial vein were prepared in all cases, only superficial vein of flap was used for anastomosis. In one case, the donor site was closed primarily, the others were closed with skin graft. The transplanted flaps survived with satisfactory recovery in function and appearance. In 2 cases, transient venous insufficiency was observed and resulted in possible increase in flap thickness. Grasp function of the hand was dramatically improved. The follow-up period ranged from 10 to 22 months. In one case, the flap required debulking. Postoperative follow-up revealed no marked donor site morbidity. We determined that the medialis pedis flap was a remarkable alternative for palmar reconstruction of the hand and digits due to burn because of its glabrous skin, which was very similar to palmar skin, and low donor site morbidity.

Are reverse flow fasciocutaneous flaps an appropriate option for the reconstruction of severe postburn lower extremity contractures?

Full thickness burns involving the lower extremity can result in severe contractures, which impair extremity functions if they are not managed with proper treatment and rehabilitation. After release of postburn contracture of the knee, ankle, and metatarsophalangeal joints, defects often require coverage by flaps. Twelve distally based reverse flow flaps were performed for lower-extremity reconstruction after release of postburn flexion contractures. All of the patients were male and their age ranged from 20 to 23 years, with a mean age of 21. After the release of the contractures, 3 flaps were used based on the location of the contractures. The reverse flow anterolateral thigh flap was used for knee reconstruction (n = 4, 33%). The reverse flow sural flap was used for ankle reconstruction (n = 4, 33%), and the reverse flow medial plantar flap was used for metatarsophalangeal reconstruction (n = 4, 33%). The sizes of the flap varied from 2 to 17 cm wide and 3 to 18 cm in length. All defects were covered successfully. Reverse fasciocutaneous tissue transfer to reconstruct the soft tissue defects provide early motion. Sufficient contracture release is achieved without displacement of anatomic landmarks. The reverse-flow flap is a reasonable and reliable choice for each joint level in the lower extremity.

Is phosphatidylcholine harmful to the peripheral neural tissue? An experimental study in rats.

BACKGROUND: Subcutaneous phosphatidylcholine (PC) injection has become a popular technique for treating localized fat accumulation. Some clinical studies reported minor local soft tissue complications, such as ecchymosis, edema, and pain. However, there are no data on how PC affects the peripheral nervous tissue. OBJECTIVE: To investigate the local effect of PC on the peripheral nervous tissue of rats. METHODS: Twenty adult Lewis rats weighing between 200 and 300 g were divided into 2 experimental groups (n=10). In group 1, animals received an intrafascicular injection of 0.1 mL PC (Lipostabil 250 mg/5 mL) with a 30-gauge needle into the left posterior tibial nerve. In group 2, as a negative control group, 0.1 mL normal saline was injected intrafascicularly respectively. After the operation, rats were evaluated on days 7, 14, and 21 with walking track analysis. On day 21, all the animals were sacrificed and the left tibial nerves were taken for histologic study. Light and electron microscopic studies, along with morphometric analysis, were performed. RESULTS: According to the tibial nerve indices, there were no signs of nerve damage observed in either of the groups, and there was no statistical difference between the groups (P> .05). The nerves that received PC and saline injections could not be distinguished grossly and appeared similar to segments of the nerve that did not come in contact with either solution. The number and diameter of fibers, the thickness of the myelin, and the percentage of neural tissue were comparable with normal controls. According to these analyses, there were no statistical differences between the 2 groups (P> .05). CONCLUSIONS: This study demonstrates that in a rat model, even direct intraneural injection of PC causes no damage. This information should encourage people to consider broader applications of PC.

The role of the vacuum-assisted closure therapy in the salvage of venous congestion of the free flap: case report.

Indications for vacuum-assisted closure (VAC) therapy described generally include acute, chronic, traumatic wounds and ulcers. Recent studies related to investigating new applications of VAC therapy have begun to be reported at literature in many aspects. We used this technique in a novel area. A 21-year-old man presented who suffered venous congestion in anterolateral thigh fasciocutaneous flap at the postoperative second day. Following two cycles of VAC therapy, 72 hours later, venous congestion disappeared. Application of VAC therapy to the flap helps removal of excess interstitial fluid because of increased pressure gradients. It seems that VAC therapy is an option in venous congestion when the interstitial pressure rises above capillary pressure.

Versatility of the reverse lateral arm flap in the treatment of post-burn antecubital contractures.

If they are not managed with proper treatment and rehabilitation, full thickness burns involving the cubital fossa may result in severe contractures that may impair upper extremity functions. Later release of these contractures discloses a large soft tissue defect that should be replaced. We used reverse lateral arm flaps for coverage of the cubital fossa in 11 selected cases of antecubital contracture. Ten flaps survived totally while we experienced one distal partial necrosis, which was later treated by skin grafting. We achieved considerable functional improvements in all cases. Although fasciocutaneous flaps offer the advantage of using regional tissue in a single stage, few versatile local flaps relying on the vascular anatomy around the elbow joint are available for cubital fossa coverage. Being a rapid, easy and one-staged procedure with no necessities for sacrifice of a major artery or muscle and for a long-term immobilization of the involved joints, reverse lateral arm flaps appears to be advantageous in comparison to other options for coverage of the cubital fossa defects after the release of antecubital contractures.

Psychological evaluation of self-inflicted burn patients: suicide or parasuicide?

Self-inflicted burns have an increasing incidence all around the world. There is a high mortality and morbidity rate among these patients. We retrospectively analysed the psychiatric characteristics of self-inflicted burn patients. The results showed that these attempts are somewhat different from suicidal acts and may be defined as parasuicides. The treatment and rehabilitation strategies of so called parasuicidal burns are discussed.

Versatility of the medial plantar flap: our clinical experience.

The medial plantar flap presents an ideal tissue reserve, particularly for the reconstruction of the plantar and palmar areas, which require a sensate and unique form of skin. In the past 5 years, the authors performed 16 free flaps, 10 locally pedicled flaps, and five cross-leg flaps on 31 patients for the reconstruction of palmar and plantar defects. All flaps transferred to the palmar area survived, providing good color match and sufficient bulkiness. The overall results were satisfactory in terms of function and sensation, and no complications related to flap survival in the plantar area were observed. All flaps used to cover defects in the heel and ankle region adapted well to their recipient areas, and all lower extremities remained functional. Because the medial plantar flap presents glabrous, sensate skin with proper bulkiness and permits the movement of underlying structures, the authors advocate its use and view this procedure as an excellent alternative in the reconstruction of palmar and plantar weight-bearing areas.

Radiotherapy: effects on expanded skin.

Although the combination of radiation and tissue expansion has been associated with a significant rate of complications, the specific pathophysiology has yet to be clearly elucidated. The objective of this study was to develop a model to identify and examine specific histologic changes associated with tissue expansion and irradiation. Rectangular 50-cc silicone tissue expanders were placed subcutaneously over the midline dorsum of 18 adult New Zealand white rabbits. Preoperative radiographic dosimetry demonstrated that the radiation portal was away from vital intraabdominal structures. The expanders were inflated with 10 cc of saline every other day for a total of 80 cc. Expanders were left in place for 2 to 3 weeks to allow fibrovascular capsule formation. The rabbits were then divided into three groups (six rabbits per group), each receiving one of three nonfractionated doses of radiation (20, 25, or 35 Gy). Half of the expanded skin was irradiated using a single dose, and the other half served as a nonirradiated control. Capsules and skin were harvested 6 weeks after the delivery of radiation, allowing the beginning of chronic radiation changes to occur. Using hematoxylin and eosin staining, histomorphometric analysis was performed. The data were analyzed using Student's test. Although irradiation did not affect dermal thickness, it did cause a statistically significant increase in epidermal thickness. At 20, 25, and 35 Gy the increase in epidermal thickness was 43, 90, and 130 percent, respectively. Although significant epidermal changes could be identified, capsular and dermal alterations were not evident. Further studies evaluating the long-term effects of alterations in capsular formation caused by radiation may be required.

Early-onset unilateral electric cataract: a rare clinical entity.

Electrical injury may result in cataracts, which usually occur bilaterally. In this report, we present a rare complication of such an injury presenting as a unilateral cataract in a 33-year-old woman with a painless but gradual worsening of vision in her left eye 3 weeks after sustaining a high-voltage electrical injury. A cataract did not develop in the right eye during 26 months of follow-up. The patient underwent successful cataract surgery with an excellent return of vision. Electrical injuries may result in the formation of a unilateral cataract and therefore an ophthalmic examination should be performed regularly in the early recovery period of such injuries. Cataract surgery with intraocular lens implantation results in an excellent return of vision in patients with electrical cataract who do not have any other ocular damage.

Thermal burns associated with the misuse of flammable liquids in stoves: a continuing problem.

Coal stoves that are used for heating purposes are more popular in economically developing and undeveloped countries because of their lower operational costs. Unfortunately, they may cause serious burn injuries when flammable liquids are misused to kindle or to accelerate a fire within them. Every year, particularly in the winter, many citizens in Turkey have suffered burn injuries caused by this dangerous practice. During the period from January 1989 to January 2009, 82 patients sustained burn injuries as a consequence of coal stove fires and were admitted to burn units. Efforts to inform the public about the danger of using flammable liquids with these kinds of stoves are recommended to minimize the incidence, morbidity, mortality, and cost of this relatively common and preventable type of injury.

Frostbite injury of hand caused by liquid helium: a case report.

OBJECTIVE: The aim of this study was to present a case report of a patient with hand frostbite injury sustained by helium vapor and discuss the circumstances of this injury, treatment, and preventive measures. METHODS: A case report of the incident was drafted and the relevant literatures were reviewed. The patient was treated with antiedema therapy, extremity elevation, high-molecular-weight dextran, heparin infusion, and hyperbaric oxygen therapy. RESULTS: The frostbite injury healed with spontaneous epithelization. At his last follow-up at the eighth month, he had a good range of movement of his hand. CONCLUSION: Frostbite injuries are relatively uncommon and have various etiologies. The adjunctive hyperbaric oxygen therapy is an alternative treatment of frostbite injuries, although it is still considered investigational.

Profile of self-inflicted burn patients treated at a tertiary burn center in Istanbul.

The factors and demographic features of self-inflicted burns in Eastern and Western cultures differ from each other. In this retrospective study, the authors' aim is to identify the epidemiologic features of self-inflicted burn patients treated at their Tertiary Burn Centre. The Burn Centre provides health care to a large population from Istanbul, which is located at the crossroads between Asia and Europe. The demographic data and information of 32 patients who were admitted to the GATA HEH Burn Center in Istanbul for attempted suicide were retrospectively reviewed over a 7-year period (2001-2008). Twenty-eight of the 32 patients were men, whereas the remaining four patients were women. The average age was 25.9 years. Seventeen patients had a previous history of self-harming and 22 patients were unemployed. History of a psychiatric illness was found in 20 patients. Mean total body burn surface area was 70%. The mortality rate was 43.4%. This study demonstrates that suicide attempts by burning differ from Eastern and Western cultures by factors and demographic features. It has been concluded that the solution to preventing self-inflicted burns calls for the joint efforts of physicians, psychologists, and sociologists. Furthermore, it is necessary to reinstate prevention programs and revise strategies for prevention based on the country and its culture.

Reverse flow flap use in upper extremity burn contractures.

Upper extremity contractures still happen and constitute one of the most trying challenges in burn patients. This series comprised of 4 radial forearm flaps, 14 dorsoulnar artery flaps, and 4 medial arm flaps, all of which were used in a reverse pattern for upper extremity postburn contractures. The reverse flow radial forearm flap (RRFF) was chosen for reconstruction of extensive palmar contractures after burn. The reverse flow dorsoulnar flap (RDUF) was used particularly for reconstruction of the hypothenar aspect of the hand which requires moderate size tissue transfer. The reverse medial arm flap (RMAF) was used for elbow contractures after burn. In the first RMAF, venous congestion occurred and was finaly resolved with minimal flap loss, which was managed with STSG later. In the following 3 cases the flap was supercharged with anastomosis of the brachial vein into the antebrachial vein. Both RRFF and RDUF may provide a smooth and efficient solution. However, RMAF has a significant venous problem, which may result in flap loss, therefore, this flap should not be considered as a first option in the elbow area.