Laser-Assisted Vascular Malformation Resection: A Novel Surgical Approach.

Vascular malformations can be treated using sclerotherapy agents like alcohol, polidocanol, or sodium tetradecyl sulfate foam and embolization treatments. These endovascular treatments may cause severe complications as pulmonary embolism and thrombosis. 980-nm diode lasers (DLs) are common devices used by many specialties as plastic surgeons, dermatologists, and vascular surgeons. Laser energy is excellently absorbed in water and hemoglobin, which makes it ideal for adipose tissue and deep lesions. We treated our patient using a DL. Our surgical approach allowed total excision of the arteriovenous malformation (AVM), which decreased the size of the tumor allowing a smaller incision and eased the dissection plane. We believe that lasers will be used more frequently on AVM treatments.

Intraductal botulinum toxin injection suppressed the inflammation in experimental acute pancreatitis.

BACKGROUND: Acute pancreatitis (AP) is inflammation of pancreas in which pancreas enzymatic activity is increased. Parasym-pathetic innervation of pancreas plays an important role in several functions of pancreas. Botulinum toxin (BTx) might be a tool to suppress the pancreas activity in AP. METHODS: In the preliminary experimental study, BTx (15U/kg) was administered directly and intraductal ways. After 10 days, blood amylase, lipase, trypsinogen, insulin, and glucagon levels were compared and no significant difference was seen between groups. Intraductal BTx administration is preferred for experimental AP model in rats; control, AP, intraductal BTx, and AP with Intraductal BTx (AP+BTx). AP was created by intraperitoneal injection of cerulean 20 µg/kg/injection (5 times). After 24 h, serum amylase, lipase, IL-6, IL-1ß, TNF-α, and IL-10 were measured and pancreas tissue was evaluated for inflammation and necrosis. RESULTS: Mean serum amylase, lipase IL-6, IL-1ß, and TNF-α levels of the AP group were significantly higher compared to the other groups (p<0.05). However, there was no significant difference between the amylase and lipase levels of control, BTx, and AP+BTx groups. Serum insulin and glucagon levels in AP group were significantly higher than control and BTx groups (p<0.05). However, there is no significant difference between the insulin and glucagon levels of AP and AP+BTx groups. in pathological evaluation. In AP+ BTx group, there is less amount of centrilobular necrosis and there is mild inflammation and hyperplasia of pancreatic duct epithelium. CONCLUSION: Administration of intraductal BTx suppressed the AP without making significant suppression in endogenous activity of pancreas.

Cutaneous adverse effects of methylene blue in an animal skin-flap model.

Background and objectives: Sentinel lymph node biopsy is important for metastasis surveillance in the management of a number of human cancers. Identification of sentinel lymph nodes may be facilitated by the use of several methods including methylene blue injection. However tissue necrosis is a known effect of methylene blue application. This study aimed to investigate the effects of methylene blue injection on skin flaps using a rodent model.Methods: Modified McFarlane flaps were prepared using Wistar Albino rats. Local injection of methylene blue was given to one group while saline was injected into the control group. A third group received systemic methylene blue via intraperitoneal injection. Observational and histological comparison was made between the groups to investigate the necrotic effects of methylene blue on skip flaps.Results: The control group's surviving flap areas were significantly larger than local methylene blue group's surviving flap area. However, there was no significant difference in skin flap survival area between the control group and the systemic methylene blue group. Furthermore, there is no significant difference between local and systemic methylene blue group's surviving flap areas.Conclusions: Local methylene blue injection increases skin necrosis and decreases rates of surviving flap areas in an experimental rat models.

Sentinel lymph node biopsy with a gamma probe in patients with high-risk cutaneous squamous cell carcinoma: follow-up results of sentinel lymph node-negative patients.

OBJECTIVE: Lymphoscintigraphy (LS) and sentinel lymph node biopsy have become the standard of care for melanoma and breast cancer. However, the data on patients with cutaneous squamous cell carcinoma (SCC) are limited. We aimed to evaluate and identify the role of LS and sentinel lymph node biopsy in patients with high-risk cutaneous SCC. METHODS: Nineteen patients (13 men, six women; 47-87 years of age, mean age 67.5 ± 12.3) with SCC were included in the study. LS was performed on all patients after intracutaneous injection of Tc-99m nanocolloid. Primary lesions and sentinel lymph nodes (SLNs) were excised with the help of a gamma probe. RESULTS: A total of 26 SLNs and 32 secondary lymph nodes were imaged on LS and were marked. During surgery, 29 SLNs, 21 secondary lymph nodes and three nonactive lymph nodes were excised. In total, 53 lymph nodes were removed surgically. A histopathological study revealed that all lymph nodes were negative for metastasis. Patients were followed up for an average of 41.1 ± 22.2 months (7-80 months). Until the time of data collection, 14 patients were alive and had no regional lymph node or distant metastasis. Local recurrence was seen in only one patient. He was reoperated upon 38 months ago. CONCLUSION: The feasibility of determining SLNs using LS and an intraoperative gamma probe in patients with cutaneous SCC was shown. Unnecessary elective lymph node dissection and possible complications could be avoided in 19 patients.

Protective effects of pentoxifylline on cigarette smoking-induced renal tissue damage in rats.

In this study, we investigated the protective effect of pentoxifilline (PTX) on smoking-induced damage in rat kidney tissues. Twenty-seven male Wistar rats were used in the study. Animals were divided into three equal groups as follows: Group 1: control group with only normal saline (NS; 0.9% NaCl) injection for 8 weeks; Group 2: cigarette smoking and NS injection for 8 weeks; and Group 3: cigarette smoking and PTX injection for 8 weeks. The rats were sacrificed after 8 weeks and their kidneys were excised for histopathological analysis. Serial paraffin sections (5 µm) of the kidneys were cut and stained with hematoxylin and eosin (H&E) and periodic acid-Schiff (PAS). The terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end labeling (TUNEL) method was used to assess apoptosis. Glomerular diameters, glomerular cell number and proximal tubule cell numbers were compared between the groups. Our results showed that PTX treatment prevented negative effects of smoking in rat kidneys. There was a statistically significant difference in all assessed parameters between Group 2 and other groups (p < 0.05). In conclusion, our study shows that PTX treatment is effective in preventing the negative effects of cigarette smoking on kidneys by inhibiting cell damage with its antioxidant properties.

Effect of silicon gel sheeting in nasal injury associated with nasal CPAP in preterm infants.

We conducted this study to investigate the efficacy of the silicon gel application on the nares in prevention of nasal injury in preterm infants ventilated with nasal continuous positive airway pressure (NCPAP). Patients (n=179) were randomized into two groups: Group 1 (n=87) had no silicon gel applied to nares, and in Group 2 (n=92), the silicon gel sheeting was used on the surface of nares during ventilation with NCPAP. Nasal injury developed in 13 (14.9%) neonates in Group 1 and 4 (4.3%) newborns in Group 2 (OR:3.43; 95% CI: 1.1-10.1; P<0.05). The incidence of columella necrosis was also significantly higher in the Group 1 (OR: 6.34; 95% CI: 0.78-51.6; P<0.05). We conclude that the silicon gel application may reduce the incidence and the severity of nasal injury in preterm infants on nasal CPAP.

Botulinum toxin for the correction of asymmetric crying facies.

The clinical hallmark of asymmetric crying facies (ACF) is a symmetric appearance of the oral aperture and lips at rest, but significant depression of one side of the lower lip with animation (crying or smiling). ACF can resolve spontaneously in the first year of life, but surgical intervention may be required at some point to ensure a good cosmetic outcome. The authors report on the successful use of botulinum toxin type A to achieve temporary facial symmetry in two children with ACF with results lasting up to six months and suggest that such treatments may be helpful in providing more time to consider and/or plan surgical intervention.

Abdominal fascial flaps for providing total implant coverage in one-stage breast reconstruction: an autologous solution.

BACKGROUND: Silicone implants are often used in immediate breast reconstruction. Complications associated with silicone-based implant reconstruction, such as capsular contracture, implant palpability, and visibility, are best avoided by placing the implant under a reliable soft-tissue cover such as the pectoralis major muscle. This muscle, however, is not always sufficient for complete coverage of the silicone implant. This is especially true for large implants. By including the fascia of the upper abdominal muscles in the reconstruction, this problem can be overcome. We describe our experience with one-stage breast reconstruction utilizing the fascia of the upper abdominal muscles to provide adequate soft-tissue coverage of the implant. METHODS: This technique was used in the reconstructions of ten patients over 4 years (2005-2009). This method was selected by the operating surgeon at the time of surgery if the pectoralis major muscle was felt to be of inadequate size to provide adequate implant coverage. The pectoralis major muscle was released from its sternal and caudal attachments to the chest wall. The rectus abdominis fascia and external oblique fascia were elevated as a combined cephalic-based flap. This fascial flap was advanced cranially and sutured to the released pectoralis major muscle after insertion of the implant. RESULTS: The mean size of the silicone implant was 448.2 cc and mean follow-up was 19.7 months. All implants were adequately covered with soft tissue at the end of each case. Complications included one patient with a hematoma, one patient with skin necrosis at the suture line, and one patient with an implant infection necessitating removal. CONCLUSION: There are many ways to provide soft-tissue coverage of silicone breast implants in breast reconstruction. These include acellular dermis slings, polyglycolic mesh, deepithelialized skin, and muscle. The ideal soft-tissue cover would be supple, easily harvested, of minimal morbidity, of minimal cost, and preferably autologous. We feel that the technique described here has these qualities and allows for complete coverage of silicone implants. An additional benefit of this technique is that it helps to increase the definition of the inframammary sulcus. This method is a good alternative in providing implant coverage during breast reconstruction, especially when there is a large implant or small pectoralis major muscle.

The effects of the pentoxifylline on survival of the skin flaps in streptozotocin-diabetic rats.

Skin flaps are frequently performed for diabetic patients in spite of countless detrimental effects of diabetes on flap survival. This study was planned because only a few clinical experiments have been performed on the effect of pentoxifylline (PTX) on the flaps in diabetic-animals. We studied 4 groups of rats: group 1, diabetic PTX treatment; group 2, diabetic control; group 3, nondiabetic PTX treatment; group 4, nondiabetic control. For the diabetic groups, diabetes mellitus was induced via intraperitoneal injection of streptozotocin (55 mg/kg). For treatment groups, PTX injections were started at the end of the 6th week of the experiment and procedures were carried out for 4 weeks during the experiment. Modified McFarlane flaps were elevated from all animals at the end of the 10th week of the experiment. Surviving areas of the flaps were measured at the end of the 11th week. Flap survival of the nondiabetic control and diabetic PTX treatment groups were significantly higher than of the diabetic control group (P < 0.01). Also, flap survival of the diabetic PTX treatment group was not statistically different than of the nondiabetic control group, but flap survival of the nondiabetic PTX treatment group was not statistically different from that of the nondiabetic control group. PTX appears to help decrease the harmful effects of diabetes on survival of the skin flaps.

Preoperative color Doppler assessment in planning of gluteal perforator flaps.

Gluteal artery perforator flaps have gained popularity due to reliability, preservation of the muscle, versatility in flap design without restricting other flap options, and low donor-site morbidity in ambulatory patients and possibility of enabling future reconstruction in paraplegic patients. But the inconstant anatomy of the vascular plexus around the gluteal muscle makes it hard to predict how many perforators are present, what their volume of blood flow and size are, where they exit the overlying fascia, and what their course through the muscle will be. Without any prior investigations, the reconstructive surgeon could be surprised intraoperatively by previous surgical damage, scar formation, or anatomic variants.For these reasons, to confirm the presence and the location of gluteal perforators preoperatively we have used color Doppler ultrasonography. With the help of the color Doppler ultrasonography 26 patients, 21 men and 5 women, were operated between the years 2002 and 2007. The mean age of patients was 47.7 (age range: 7-77 years). All perforator vessels were marked preoperatively around the defect locations. The perforator based flap that will allow primary closure of the donor site and the defect without tension was planned choosing the perforator that showed the largest flow in color Doppler ultrasonography proximally. Perforators were found in the sites identified with color Doppler ultrasonography in all other flaps. In our study, 94.4% flap viability was ensured in 36 perforator-based gluteal area flaps. Mean flap elevation time was 31.9 minutes. We found that locating the perforators preoperatively helps to shorten the operation time without compromising a reliable viability of the perforator flaps, thus enabling the surgeon easier treatment of pressure sores.

Fournier's gangrene in childhood: a report of 3 infant patients.

Fournier's gangrene is uncommon in pediatric age group, and little is known about the disease in the newborn period and infancy. Three patients, aged 10 days, 14, and 17 months, with Fournier's gangrene, were treated in our hospital. The predisposing factors were prematurity, a diaper rash, and varicella infection, respectively. Especially, prematurity and diaper rash are rare predisposing factors in the pediatric population; therefore, high index of suspicion, prompt diagnosis, conservative surgery, and multidisciplinary approach are the mainstays of management in children with Fournier's gangrene.

Use of diced bone grafts wrapped in surgicel in the augmentation of maxillofacial area.

The correction of asymmetry in craniomaxillofacial region presents many problems for reconstructive surgeons. For this purpose, varieties of different materials and techniques have been used. We present our experience with diced bone graft wrapped in Surgicel applied to 5 patients with facial atrophy due to various causes between the years 2005 and 2008. The average follow-up period was 18 months (range, 9-25 months). All bone grafts were diced into small pieces with a maximum size of 2 to 3 mm using a costotome. The smaller bone grafts were prepared according to the technique described by Erol (Plast Reconstr Surg. 2000;105:2229-2241) for cartilage grafts. Results of the patients' satisfaction were well. Wrapping bone grafts in Surgicel holds them together. Thus, it becomes easier to adapt the diced bone grafts to the area to be augmented. Molding of diced bone grafts wrapped in Surgicel in accordance with the three-dimensional structure of the face with gentle movements after adaptation is an important advantage, which classical bone grafts do not have. In the later periods, collagen-enhancing effect of Surgicel not only prevents the bone grafts' being noticed, but also softens its consistency. This in turn facilitates adaptation of bone grafts to the facial area.

A new application for increasing breast projection in free-nipple-graft reduction mammaplasty.

BACKGROUND: Free-nipple-graft reduction mammaplasty is the procedure of choice in patients with massive breast hypertrophy. Breasts that have undergone free-nipple-graft reduction mammaplasty usually cannot maintain projection. Many modifications of free-nipple-graft reduction mammaplasty have been described to treatment this problem. We describe our modification of the free-nipple-graft reduction mammaplasty. METHODS: The technique includes two key points: The first is the fold of the midportions of the breast. The second is suturing the midportion of the breast to the fascia of the pectoral muscle. The fold increases breast projection and the suturing helps to obtain long-lasting breast projection. RESULTS: A total of 16 patients underwent free-nipple-graft reduction with the modified technique between 2003 and 2008. Mean follow-up was 21 months (range = 3-60 months). An average of 2016 g of tissue per breast was excised (range = 1250-2700 g per breast). An average of 4031 g of tissue per patient was excised. All patients had long-lasting, pronounced breast mound projection. Satisfactory breast projection was maintained. No "bottoming out" was seen. The level of satisfaction felt by all patients was very high. CONCLUSION: Long-term projection can be maintained by suturing the half-trianges to each other and to the fascia of the pectoral muscle. One more useful alternative technique for increasing projection in free-nipple-graft reduction has been added with the technique presented.

Three-dimensional nasal reconstruction using a prefabricated forehead flap: case report.

Surgical treatment is extremely difficult with the combined defects of skin, cartilage, and nasal mucosa. Besides efforts geared toward ascertaining the best aesthetic outcome, an important concern is restoring normal nasal function. This can be achieved only by providing sufficiently and anatomically adapted cartilage and bone support, followed by covering the inner part using tissue closely resembling mucosa and the outer part using skin compatible with the surrounding skin. The surgical technique for three-dimensional nasal reconstruction in the first session of this study involved placing a silicon sheet between the skin and galea, which allowed two separate flaps to be obtained for the next session without vascular damage. For the epithelialization of the defect on the nasal surface, the lower surface of the galea was prefabricated with a thin skin graft obtained from the thigh. In this way, nasal mucosa cover was ensured. The expander placed under all these structures thinned them down to a thickness close to that of nasal skin and mucosa and also enabled primary closure of the donor area. Thus, the defect that emerged during the second session in cartilage framework was repaired by cartilage grafts taken from the nasal septum. The mucosal surface and skin part then could be closed with two separate flaps. The forehead flap used in this technique enabled production of an aesthetically and functionally satisfactory outcome by providing an anatomically sufficient amount of nasal skin and nasal mucosa for whole-layer wide nasal defects in only three sessions without necessitating an additional flap.