Nasal Filling in Plastic Surgery Practice: Primary Nasal Filling, Nasal Filling for Post-rhinoplasty Defects, Rhinoplasty After Hyaluronidase Injection in Dissatisfied Nasal Filling Patients.

BACKGROUND: Nasal filling has gained popularity in plastic surgery practice and strengthened the surgeon's hand. Mild deformities of the nose can be treated with nasal filling instead of rhinoplasty, or small contour irregularities following surgical rhinoplasty can be corrected by dermal filler injections. It is a significant advantage of hyaluronic acid (HA) fillers that they can be dissolved with hyaluronidase in case of the patient dislikes the appearance and desires a surgical rhinoplasty. However, there is no publication about when rhinoplasty surgery can be performed safely after hyaluronidase injection. OBJECTIVES: In this case series, we shared our experiences with nasal filling in plastic surgery practice under three headings: primary nasal filling, nasal filling for post-rhinoplasty defects and rhinoplasty after hyaluronidase injection in dissatisfied filling patients. We presented our nasal filling technique, indications, result analysis and also our rhinoplasty experiences we performed at different times after hyaluronidase injection. METHODS: Nasal filling patients from July 2015 to March 2020 were divided and analyzed in three groups: (a) Primary nasal filling was provided to 62 patients, (b) nasal filling for post-rhinoplasty defect was provided to 18 patients, and (c) rhinoplasty after hyaluronidase injection was performed in five patients who are not satisfied with results. The duration between hyaluronidase and rhinoplasty operation was, respectively, 6 months, 3 months, 3 months, 2 months and 1 week. RESULTS: (a) In primary nasal filling, 57 patients were fully satisfied, two patients were satisfied, and three patients were dissatisfied with results. Results were stable up to at least 6 months (Range 6-14 months). (b) In nasal filling for post-rhinoplasty defects, all patients were fully satisfied with results. Results were stable for at least 12 months (Range 12-36 months). (c) In rhinoplasty after hyaluronidase injection, any filling residue was not observed, and there were no complications. The postoperative results were satisfactory. CONCLUSION: Nasal filling with hyaluronic acid represents an excellent alternative for patients who do not wish to undergo a rhinoplasty or a revision rhinoplasty procedure. HA filler can be dissolved easily with hyaluronidase if the patient does not like the result, and we think that rhinoplasty can be performed safely at least one week later from hyaluronidase treatment. 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 .

Functional lower lip reconstruction with the partial latissimus dorsi muscle free flap without nerve coaptation.

BACKGROUND: The repair of extensive lower lip defects is difficult due to the presence of both functional and esthetic requirements. This report describes functional lip repair using the partial latissimus dorsi free flap without nerve coaptation. METHODS: Reconstruction of the lower lip due to subtotal and total tissue defects was performed using latissimus dorsi free flap on twelve patients, between 2013 and 2017. The etiology was squamous cell carcinoma in six patients, malignant melanoma in one, firearm injury in three and microstomia in two. Following exposure of the lip defect, the partial latissumus dorsi muscle flap was harvested and transfered into the lower lip defect. The microvascular anastomoses was done and no nerve coaptation was performed. The muscle was covered with a skin graft taken from the thigh for mucosal and skin lining. Functional outcomes were assessed using physical examination, electromyography (EMG), electroneuromyography, cold/warm and pain sensation, two point discrimination (TPD), and Semmes Weinstein (SMW) tests. RESULTS: Postoperative course was uneventful for all of the flaps. Patients were followed for between fifteen months and four years (mean 28.2 months).Color match between the flap and the face and functional outcome was satisfactory. Reinnervation was detected at EMG in eleven patients undergoing surgery six months postoperatively.After 1 year, the patients demonstrated quite normal results of the test with SMW and TDP results. None of patients perceived both hot and cold sensation. CONCLUSION: The technique is an alternative option in lower lip reconstruction since it provides satisfactory functional and esthetic results despite absence of any neural coaptation.

Experiences with functional gracilis muscle flap in lower lip reconstruction.

OBJECTIVE: Reconstruction of the lips is pivotal because the lips play an essential role in facial aesthetics and have unique functional properties. We presented our experience in reconstruction of total or subtotal lower lip defects with functional gracillis muscle flap covered split-thickness skin graft (STSG) in patients. METHODS: Between 2009 and 2011, seven patients underwent resection of lower lip squamous cell carcinoma and lip reconstruction. Gracillis muscle flap was performed for reconstruction. Recipient vessels were the facial artery and vein. Motor nerve of the gracillis muscle was coapted to the marginal branch of the facial nerve. Gracillis muscle was covered with STSG. Patients were evaluated about mouth opening, oral competence, word articulation, the color match of the graft, the contraction of the muscle by physical examination. Electromyographic studies and sensation tests were performed. RESULTS: Postoperative course was uneventful for all of the flaps. No microvascular revisions were needed. One patient was reoperated because of wound dehiscence under local anaesthesia. Mean follow up period was 15 months. After three months, movement of the reconstructed lip was observed. Color of the grafted skin was matched with the skin of the face. The patients had no problems with word articulation, oral continence, or mouth opening. The electromyographic study showed recovery of motor innervation. After 1 year, the patients demonstrated recovered sensitivity with the sensation test. CONCLUSION: Considering functional results, superior aesthetic appearance, and minimal donor-site morbidity of the functional gracillis transfer covered skin graft, we think that this method may be an alternative for reconstruction of large full-thickness defects of the lower lip. © 2015 Wiley Periodicals, Inc. Microsurgery 37:487-493, 2017.

Consideration of difficulties and exit strategies in a case of face allotransplantation resulting in failure.

We describe the first rescue procedure in a case of total face allotransplantation. The recipient was a 54-year-old man with severe disfigurement of the entire face following an accidental gunshot injury 5 years previously. The large defect included the maxilla, mandible, and mid-face. Full face procurement was performed from a multiorgan cadaveric donor and was allotransplanted to the recipient. The post-transplant induction immunosuppressive regimen included ATG combined with tacrolimus, mycophenolate mofetil, and prednisone, while maintenance was provided by the last three of these. Although the early postoperative period was uneventful, squamous cell carcinoma developed in the upper and lower extremities in the fifth postoperative month, and post-transplant lymphoproliferative disorder (PTLD) occurred in the sixth month postoperatively. Malignancies were treated, involving both surgical and medical approaches. The patient developed opportunistic pulmonary and cerebellar aspergillosis. In order to reduce the adverse affects and metabolic and immunological load, the transplanted face was removed and replaced with a free flap. Although the early postoperative period was promising, with the transferred flap surviving totally and all vital signs and general status appearing to be improving, the patient was eventually lost due to complicated infectious and metabolic events. Although this case was unsuccessful, we suggest that the immunological and metabolic load should be reduced as soon as stable medical conditions are established in case of diagnosis of a situation involving a high rate of mortality, such as PTLD and untreatable opportunistic infections. This should include withdrawal of all immunosuppressive drugs and removal of all allotransplanted tissues.

Experiences with the flow-through radial forearm flap as a bridge in lower extremity reconstruction.

Various techniques have been proposed in order to overcome recipient vessel problems in microsurgery. In cases with no suitable recipient vessels close to the defect, the flow-through flap is a valuable and reliable alternative for accessing healthy recipient vessels in a single stage. We describe our experiences with combined flaps and discuss the advantages of the flow-through radial forearm flap as a bridge. Between 2003 and 2009, eight combined flaps were used to reconstruct soft-tissue defects of lower extremities. Seven patients had acute or subacute wound with exposed bone and vascular injury caused by trauma, one had a chronic nonhealing wound. The flow-through radial forearm flap was used as a bridge flap with combined a cover flap in all cases. Radial forearm flaps provided recipient vessel lengthening. In one patient, the distal ALT flap failed and replaced with latissimus dorsi flap. Other postoperative courses were uneventful and all of flaps survived. In one patient although the flaps were healthy, sepsis developed and the extremity was amputated. Recovery and ambulation were achieved in the remaining patients. Combined flaps with the flow-through radial forearm flap are an appropriate technique for overcoming recipient vessel problems. Although the technique involves a more complicated procedure and increases the number of microvascular anastomoses, it is a valuable, safe and comfortable alternative in selected cases.

The Relationship Between Ischemia Time and Mucous Secretion in Vaginal Reconstruction With the Jejunal Free Flap: An Experimental Study on the Rat Jejunum.

Jejunum flap for reconstruction of the vagina provides a durable, stable coverage; patent tube passage; and natural esthetic appearance. However, excessive mucous secretion is a major drawback of the technique.We have recently presented our cases in which strict 3-hour ischemia with lower mucus secretion was applied. However, a quantitative analysis of goblet cells of the jejunum subjected to ischemia and ischemia-reperfusion injury on an animal model has not been reported to support this argument.Because goblet cells are responsible for the production and the maintenance of the mucous blanket, we aimed to determine whether goblet cell numbers decrease after ischemia and ischemia-reperfusion injury.This study was conducted on 3 groups of 10 animals. We applied to the rat jejunum only ischemia in group 1, one hour of ischemia followed by reperfusion in group 2, and 2 hours of ischemia followed by reperfusion in group 3. Histological samples taken from the jejunum exposed to ischemia and ischemia-reperfusion injury were evaluated in terms of goblet cell numbers, inflammation, apoptotic bodies, and necrosis.Goblet cell numbers significantly decreased in the group of animals exposed to ischemia and exposed to ischemia-reperfusion injury. We think that mucus hypersecretion of the jejenum can be limited by applying a longer period of ischemia time during free flap transfer in vaginal reconstruction.

Comparing different postconditioning cycles after ischemia reperfusion injury in the rat skin flap.

Ischemic postconditioning is a useful manipulation to reduce the undesirable effects of ischemia-reperfusion (I/R) injury. The beneficial results of this phenomenon against I/R injury have been seen in several flap models. However, there are no published works comparing different postconditioning (post-con) cycles in skin flaps. In this study, we investigated the effectiveness of different post-con cycles in a skin flap model. Epigastric island flap (6 × 3 cm) model which was based on the left superficial epigastric artery and vein was used, and complete 6 hours of ischemia was generated by occlusion of the pedicle. Forty male Wistar rats were allocated into 5 groups (n = 8 in each group). Group 1 (sham group): the elevated skin flap was repositioned without an episode of ischemia. Group 2 (control group): skin flap was elevated and 6 hours of complete ischemia was induced by clamping the pedicle. Group 3 (post-con 1): After ischemia, post-con was performed by 6 cycles of 15 seconds of repeated I/R periods. Group 4 (post-con 2): After ischemia, post-con was performed by 6 cycles of 30 second of repeated I/R periods. Group 5 (post-con 3): After ischemia, post-con was performed by 6 cycles of 60 second of repeated I/R periods. Flap viability was assessed 1 week after the surgical procedure, the necrotic area of the skin flap was measured using image analysis on the computer. The area of flap necrosis was statistically significant between the control and post-con group 4 and group 5, and no statistically significant difference was obtained between the control and post-con group 3. Groups 4 and 5 demonstrated lesser area of flap necrosis than the control group and group 4 was superior to group 5. The results revealed that the post-con applied by means of 6 cycles of 30 seconds yields the best protection against I/R injury in the rat skin flap model.

Reconstruction of distal lower extremities defect using the free peroneal artery perforator vessel based flap.

Soft tissue defects of the distal lower extremities are challenging. The purpose of this paper is to present our experiences with the free peroneal artery perforator flap for the reconstruction of soft tissue defects of the distal lower extremity. Nine free peroneal artery perforator flaps were used to reconstruct soft tissue defects of the lower extremities between April 2006 and October 2011. All flaps were used for distal leg and foot reconstruction. Peroneal artery perforator flaps ranged in size from 2 cm × 4 cm to 6 cm × 12 cm. The length of the vascular pedicle ranged from 2 to 6 cm. Recipient vessels were: medial plantar vessels in seven cases, the dorsalis pedis vessel in one, metatarsal vessel in one. All flaps survived completely, a success rate of 100%. Advantages of this flap are that there is no need to sacrifice any main artery in the lower leg, and minimal morbidity at the donor site. This free perforator flap may be useful for patients with small to medium soft tissue defects of the distal lower extremities and feet.

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.

Comparing various surgical delay methods with ischemic preconditioning in the rat TRAM flap model.

Both surgical delay and ischemic preconditioning (IP) have been shown to be effective in improving the survival of flaps. We used a variety of flap delay methods and IP to increase the surviving area of the transverse rectus abdominis musculocutaneous (TRAM) flap in rats, and the results are compared in between. A 6-× 3-cm-sized TRAM flap in 40 Wistar rats was allocated into five groups. Group 1: TRAM flap was elevated from nondominant pedicle, and the flap was sutured to the original bed. Group 2: Left superior deep epigastric vessels (SDEV) were cut; 1 week later, TRAM flap was elevated. Group 3: Only skin incision was done; 1 week later, TRAM flap was elevated. Group 4: Skin incision was done, and the left SDEV were cut; 1 week later, TRAM flap was elevated. Group 5: TRAM flap was elevated; IP was performed using three cycles of 10 minutes of repeated ischemia/reperfusion (I/R) periods, and the flap was sutured to the original bed. The surviving area of the flap was statistically significant between the control and groups 2, 4, and 5 (p < 0.001), and groups 4 and 2 were superior to group 5. Although preconditioning has been intensively studied for the last two decades and partly provided its beneficial effects in I/R injury, we determined the IP increased the surviving area of the TRAM flap but not effective as much as surgical delay method.

Comparing the effects of pedicle torsion on axial or perforator flaps; improving the perforator flap resistance to pedicle torsion with delay phenomenon.

BACKGROUND: The torsion of the flap's pedicle is one of the most common conditions causing vascular compromise. We aimed to compare the resistance to torsion of axial flap pedicle and perforator pedicle patterns. In the second part of the study, we investigated whether the delay phenomenon is an effective method for improving perforator flap resistance to pedicle torsion. METHODS: In the first phase, 90 male Wistar rats were randomly divided into two groups: perforator and axial. Bilateral groin flaps were elevated in the axial group and bilateral posterior thigh perforator-based flaps were elevated in the perforator group. Viable flap areas were compared at 90, 180, 270, 360, and 720 degrees of pedicle rotation. Microangiographic and histopathological studies were performed. RESULT: As a result, necrosis was seen following earlier rotation in the perforator group and viable flap areas were also lower. In the second phase, after delay procedure, the perforator flaps were exposed to 270, 360, and 720 degrees of pedicle rotation. With the delay procedure, no significant difference in viable flap areas was observed. CONCLUSION: In conclusion, the resistance to torsion of the axial flap pedicle pattern was greater than that of the perforator pedicle pattern, and the delay procedure was not an effective method for improving flap resistance to torsion.

Complex partial nasal reconstruction using free prelaminated temporoparietal fascial flap.

The reconstruction of nasal defects together with nasal lining, skeletal support, and skin loss constitutes difficulty to plastic surgeons. We present a single-stage reconstruction of the defect formed on the nasal tip, columella, septum, and upper lip after tumor excision by performing free temporoparietal fascial flap, costal cartilage, and skin graft. In this case, cartilage support was created by the graft taken from costal cartilage, and free temporoparietal fascial flap was wrapped around this cartilage scaffold. Skin graft taken from scalp was placed on the skin surface, and skin graft taken from the thigh was placed on the mucosal surface. Vascular anastomoses were performed on the labial artery and the concomitant vein. In consequence of this operation, a nasal reconstruction with acceptable esthetic and functional results was provided in a complex nasal defect. Internal lining, skin, and cartilage structures were replaced in one single stage and with single flap and graft.

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 .

[A successful replantation of total scalp, forehead, left ear, eyebrows and upper eyelids amputation and 6-year follow-up results]. / Total skalp, alin, sol kulak, kaslar ve üst gözkapaklari amputasyonunun basarili replantasyonu ve 6 yillik takip sonuçlari

Despite the technical difficulties, microvascular replantation is the outstanding method of treatment for avulsed scalps because of superior aesthetic results and social and psychological benefits. We presented a successful replantation of almost the whole of the scalp as well as the left ear, the entire forehead, eyebrows, and upper eyelids. Functional assessment of the case in the postoperative sixth year was reported.

Subcutaneous placement of a free jejunum and pedicled colon segment to create a diversionary conduit for total esophageal reconstruction.

In this report, we describe a case of difficult esophageal reconstruction with a pedicled colon segment interposition and a free jejunal flap. Laryngectomy and bilateral neck dissection for larynx carcinoma had been attempted in a 59-year-old patient 6 years previously. The patient then received radiotherapy. One year later, large resection was performed due to recurrence of the tumor. Since then the patient had been fed through a gastrostomy tube. Previous attempts at esophageal reconstruction in other institutions were unsuccessful. We reconstructed the total esophagus with subcutaneously tunneled pedicled colon segment interposition and a free jejunal flap using the diversionary loop technique to divert the passage of the foot from the pharynx to the new inlet at the buccogingival sulcus, thus keeping the native esophagus untouched. Following a postoperative training period, the patient learned to swallow successfully and smoothly via the new inlet. The patency of the newly reconstructed esophagus was corroborated by radiological imaging. In summary, although the technique requires complex surgical procedures, it is effective and may be considered as an alternative and reliable option in selected cases.

Malignant melanoma developed on a congenital melanocytic nevus with lymph node metastasis in a 19-month-old boy.

Although rare, malignant melanoma occurs in children. The risk of degeneration of a congenital melanocytic nevus into a melanoma is approximately 0.7%. We report a case of malignant melanoma that developed on a congenital melanocytic nevus in a 19-month-old boy. The child was treated by surgical resection, superficial parotidectomy, and modified radical neck dissection with adjuvant therapy. The follow-up has been 24 months without metastasis. Early clinical detection, fast histological confirmation, prompt surgery, and adjuvant therapy are the only means to achieve a long survival period for children suffering from malignant melanoma.

Superiority of medial circumflex femoral artery perforator flap in scrotal reconstruction.

Scrotal skin has unique cosmetic and functional features that make its reconstruction difficult. Coverage of the testicles and constituting a good cosmetic appearance are major expectations from a successful reconstruction. Usually flaps are the choice for scrotal reconstruction, but every single flap has its own characteristics. In our series, between January 2006 and January 2010, the medial circumflex femoral artery perforator flap was used in 7 male patients for scrotal coverage after Fournier gangrene. Six flaps were raised based on a single perforator from the gracilis muscle; however in one flap 2 perforators were used. Flaps were carried to the defect either by transposition or by V-Y advancement. Donor areas were closed directly in all patients, and stable scrotal coverage was achieved with an acceptable scrotal contour and cosmesis. No major complication was seen due the perforator flap surgery, in 2 patients wound dehiscence were noted and they healed by secondary intention or by secondary suturing. For scrotal reconstruction, the medial circumflex femoral artery perforator flap is a good option with its good mobility, thinness for scrotal contour, possibility for muscle preservation, and direct closure of the donor site. All these advantages can be accomplished in 1 procedure.

Robotic harvesting of the omental flap: a case report and mini-review of the use of robots in reconstructive surgery.

This study describes the robotic harvesting of a free omental flap. The patient was a 58-year-old man who had undergone several previous operations due to osteomyelitis caused by trauma. There was a non-healing wound and purulent discharge in the distal pretibial region. The flap was harvested based on the right gastroepiploic artery using robotic facilities only. The flap was then transferred to the debrided defect in the pretibial region. Anastomoses were performed between the posterior tibial vessels and the pedicle of the flap. A split thickness skin graft was used to cover the omental flap. The operation lasted 2.5 h in total, including flap harvesting, microvascular anastomoses, inset and skin grafting. The postoperative period was uneventful and the patient was discharged on the 12th day postoperatively. The reliability of the technique is discussed in this report, together with a brief review of the use of robot surgery in reconstructive surgery in the literature.