A New Convenient Incision Model of the Nipple-Sparing Mastectomy: Lateralized Parabolic Multiplanar Incision.

BACKGROUND: In this study, a lateralized parabolic multiplanar incision was defined. It was aimed to reduce necrosis in the nipple-areola complex (NAC) and, in the long run, to prevent the scar from pulling the areola laterally by maintaining healthy skin tissue between the scar and the areola and preserving the natural round appearance of the areola. Moreover, we purposed the scar not to be visible from the anterior view. METHODS: The study included 243 patients who underwent nipple-sparing mastectomy and immediate implant-based breast reconstruction. The incision was made 4-5 cm away from the lateral border of the NAC. The incision was completed after passing the anterior axillary line by drawing a parabolic curve in superolateral axis. RESULTS: The mean follow-up period was 24.6 months, and the mean age of the patients was 42.3 years. Full-thickness necrosis of the NAC occurred in 3.6% of breasts. In long-term follow-ups, the incision scar measured an average length of 8.6 cm. None of the patients had lateral displacement of the NAC. The NAC preserved its round appearance, except for 12 breasts that had full-thickness NAC necrosis. Ten breasts had an unnatural breast appearance. CONCLUSION: The lateralized parabolic multiplanar incision is an ideal incision model for nipple-sparing mastectomy, as it allows for the exposure and reconstruction of all breast quadrants. We maintain areolar circulation; there are no visible scars when viewed anteriorly. Furthermore, it prevents lateral displacement of the NAC, ensuring that the natural round form of the NAC is not distorted. 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 .

Expanding Usage of Superior Pedicled Techniques with Reducing Resistance in the Pedicle by Lipoaspiration.

BACKGROUND: Despite the advantages of the superior pedicles in breast reduction, there are some limitations with this technique. The mobility of the pedicle may be augmented by liposuction in the pedicle area which may relieve tissue resistance and decrease pedicle compression in order to overcome circulation problems. In fact, the indications of breast reduction using superior pedicles may be expanded by liposuction in the pedicle area. METHODS: The patients who underwent breast reduction with superior pedicle techniques between March 2014 and November 2020 and whose pedicle resistances were decreased by liposuction were included in this study. Internal breast morphology was classified into three groups based on the morphology of the periareolar tissues. Group 1 breasts were lipomatous, Group 2 breasts were lipo-glandular and Group 3 breasts were fibroglandular. During the short-term follow-up, the circulation of the nipple-areola complex (NAC) was evaluated both clinically and with an hand held Doppler device. The long-term aesthetic results were evaluated at the postoperative twelfth month with a visual analogue scale. RESULTS: One hundred eighty-nine patients with either Group 1 or Group 2 breasts were included in this study. The mean age of the patients was 38.3 years. The mean follow-up period was 31.7 months. Neither partial nor total NAC loss was observed and none of the patients had bottoming-out deformity. CONCLUSION: Liposuction to the pedicle area is an effective and reliable method that both reduces the resistance in the pedicle and overcomes the circulation problems in certain patient groups (groups 1 and 2), increases the mobilization of the pedicle, reduces the breast to the desired size and prevents bottoming-out in the long term and increases the use of superior pedicle techniques. According to our clinical results, it was demonstrated that pedicle vascular mapping with preoperative Doppler sonography was not necessary in these patients. 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 .

Reduction of the scar burden at the donor area of the radial forearm flap with the aid of an endoscopic pedicle preparation.

BACKGROUND: The radial forearm flap is one of the most commonly used flaps of reconstructive microsurgery with its long pedicle and thin structure. The donor site at the forearm is a visible anatomic region that has high mobility and functional importance. In this study, a longitudinal and large scar was avoided on the forearm during pedicle dissection of the conventional radial forearm flap with the utilization of an endoscope. Furthermore, arterial, venous, and nervous injuries were avoided by performing a separate inci-sion of 2-3 cm at the cubital fossa to reduce flap failure and donor site morbidity. METHODS: The patients who underwent pedicle dissection of the radial forearm flap with the aid of an endoscope for head-neck reconstruction between 2014 and 2021 were included in this study. The flap was harvested from the subfascial plane. The cephalic vein was used in all of the patients. When the pedicle dissection reached the antecubital region, an incision of 2-3 cm was performed from the skin. Two vein anastomoses were performed for each patient. RESULTS: This retrospective study consists of 51 patients. While 45 of the patients were the result of head and neck cancer, six of them had a defect caused by trauma. The average area of skin islands was 40.3 cm2, while the full-thickness skin graft size was 24.2 cm2. An average of 2.6 cm of scar tissue was formed at the antecubital region. No venous or arterial compromise was observed in the post-operative period. There was no partial or total flap loss in any patient. Localized numbness persisted in the skin area where the superficial sensory branch of the radial nerve is located in 6 (11.7%) patients. CONCLUSION: With endoscopic radial forearm flap harvesting, the longitudinal incision in the forearm and wound healing prob-lems are avoided. The absence of partial or total flap loss has shown that endoscopic harvesting of the radial forearm flap is a safe and reliable method.

Implant selection in natural and stable direct-to-implant reconstruction with ten steps at nipple-sparing mastectomy.

Direct-to-implant reconstruction is one of the breast repair techniques after mastectomy. Implant selection is critical in the short- and long-term success of direct-to-implant reconstruction after nipple-sparing mastectomy. In this study we developed a 10-step algorithm that we use before and during surgery. We aimed to obtain natural and stable breast reconstruction with this algorithm. In addition, we also aimed to evaluate which implants were selected using this algorithm and their short- and long-term outcomes. This retrospective study included 218 patients aged 27 to 60 years who underwent mastectomy and direct-to-implant reconstruction between November 2018 and December 2021. The patients were assigned into 4 groups according to amount of breast tissue removed. We developed a 10-step algorithm and these included: breast base, amount of breast tissue removed, evaluation of mastectomy skin flap, breast projection, ptosis, unilateral/bilateral reconstruction, chest wall deformity, patient's request, comorbid conditions and stabilization and arrangement of novel sulcus. The evaluation was made when the patient's photographs were taken at least 1 year after the surgery. The highest number of patients was recorded in group 3; in addition, mean age was also highest in group 3. The lowest number of patients was recorded in group 4. The body mass index showed a progressive increase from group 1 to group 4. Medium height moderate profile prosthesis was used in 81.7% while medium height moderate plus profile prosthesis was used in 18.3% of breasts included. We used larger prosthesis up to 58.1% when compared to the tissue removed in group 1 while we used smaller prosthesis by 25.6% in group 4. In the anterior view, the medial and lateral arch of the lower pole of the breast was obtained in all patients. Obvious asymmetry developed in 4 patients. In lateral and oblique views, upper and lower pole natural breast images were obtained in all patients, except for 5 patients. There was no sulcus inferior displacement in any patient. Implant extrusion did not occur in any patient. This algorithm is an easy to use and effective method to obtain a stable and natural breast image in the long-term.

Simultaneous Breast and Nipple-Areolar Reconstruction Using Musculo-derma-glandular, Axio-perforator, Bipedicled Flap.

Although breast reconstruction has been performed for centuries, there is a constant search for new approaches to achieve an aesthetically pleasing appearance while causing minimal patient morbidity. In our previous article, we have described our experience with the bipedicled musculo-derma-glandular, axio-perforator flap. The main advantage of this well-vascularized flap is the ability to restore the shape after mastectomy while removing the excess tissue from the hypertrophic and ptotic healthy breast. Based on our promising results with this technique in the previous two patients, we combined the breast reconstruction using bipedicled musculo-derma-glandular, axio-perforator flap with simultaneous nipple-areolar complex reconstruction. The surgery was successful, and the patient did not experience any complications. We believe this technique can be applied for patients with breast hypertrophy and ptosis to achieve reliable and aesthetically acceptable results in a one-stage operation.

Comparative Analysis of Using Bone Graft, Hydroxyapatite Coralline (Biocoral®) and Porous Polyethylene (Medpor®) Implants for Cranioplasty in a Rat Model of Cranial Bone Defect.

AIM: To compare the efficacy of bone graft, hydroxyapatite coralline (Biocoral®), and porous polyethylene (Medpor®) implants for cranioplasty in a rat model of cranial bone defects. MATERIAL AND METHODS: Two parietal bone defects were created in each of 16 male Sprague-Dawley rats. One was repaired with a bone graft using bone removed from the contralateral defect, and the other was filled with either Medpor® or Biocoral® (each n=8, with the repair on the left in four and the right in the other four). The rats were sacrificed at either 4 or 8 weeks, and implant stability, volumetric changes, and histological parameters were compared between the three materials. RESULTS: At 8 weeks, scores for bone formation (p=0.003), healing of the defects (p=0.008), and material resorption (p=0.010) were higher for the bone grafts than for Biocoral® and Medpor®, whereas the fibrosis scores were significantly higher for Medpor® and Biocoral® than for the bone grafts (p=0.004). The other parameters were similar between the three materials at 8 weeks, except for significantly higher inflammatory cell infiltration with Medpor® than with Biocoral® and bone grafts (p=0.005). CONCLUSION: Implant stability scores were similar for the three implant materials. However, there was better bone formation and healing of the defects with bone grafts, a lower risk of resorption and greater fibrosis induction with Medpor® and Biocoral®, and less volumetric reduction with Medpor®.

Use of Muscle Graft Versus Fascia Flap as Interpositional Material in Prevention of Reossification in a Rat Model of Skull Bone Defect.

AIM: To investigate the utility of two different interpositional materials (muscle graft vs. fascia flap) for preventing the osseous reunion of skull bone defect including the coronal suture line in rats. MATERIAL AND METHODS: A total of 32 male Sprague-Dawley rats were divided into 2 groups (n=16 for each) after the formation of bilateral coronal bone defect, based on the interpositional materials used to prevent re-ossification; the rats were divided into the muscle graft (MG) group and the fascial flap (FF) group. In each group, the other side of the coronal suture served as the control. The rats were sacrificed at postoperative 4 weeks or 8 weeks for histopathological, radiological, and microbiologic investigations. RESULTS: At postoperative 8 weeks, there was partial reunion in the defects with bony tissue in both the groups; no obvious differences were noted between the groups on radiological examination.The defect content involved bone and fibrous tissue in the MG group and bony bridges and loose connective tissue in the FF group. New bone formation was moderate, marked, and extreme and the reduction in defect size was marked, moderate, and extreme in the MG, FF, and control groups, respectively. CONCLUSION: Our findings revealed that neither the temporal MG nor the temporal FF were able to achieve complete prevention of re-ossification of the skull bone defects including the coronal suture line; further, neither material was superior to the other.

Supercooled Liquid Serum Physiologic Solution Instantly Crystallized on the Nurse Table Used for Cooling of Periorbital Region During Rhinoplasty.

INTRODUCTION: Formation of less periorbital ecchymosis in post-operative period of rhinoplasty is a popular trend. We present the use of instantly crystallizing supercooled serum physiologic solution for periorbital cooling. PHYSICS OF SUPERCOOLING: There are circumstances in which water temperature drops below its freezing point, but no phase transition happens while water remains in the liquid phase. This is called supercooling. Pure water can be supercooled below the freezing temperature without transforming into ice. Tap water will not supercool because it contains impurities that serve as nucleation sites for crystallization. For freezer temperatures in the range of - 4 °C, - 6 °C, and - 8 °C, nucleation was not observed and pure water remained in the supercooled condition for a long time. DESCRIPTION OF THE TECHNIQUE: Sterile serum physiologic solution at + 5 °C can be supercooled in the freezer at - 14 °C only between the 257 and 277 min time interval. But when it is supercooled in the freezer at - 8 °C it is possible to save it in liquid form for at least 7 days as we have observed in our trials. CLINICAL USE AND DISCUSSION: It is easily possible to transform this supercooled liquid sterile serum physiologic within a few seconds into moldable snow-like ice that can be used safely and more nicely rather than solid ice for periorbital cooling in rhinoplasty operations. Its sterile inner bag is held tight and struck over the sterile nurse table and it crystallizes within a few seconds. For frozen solutions, tearing of the inner plastic bag and extracting the ice and then crushing of big masses of ice to small pieces is exhaustive and a time-consuming process. The temperature of the supercooled fluid will be zero at the moment of nucleation with no risk of frostbite. The crystallized serum physiologic solution preserves its ice-gel form for nearly 25 min. CONCLUSION: The instant crystallization of supercooled liquid serum physiologic solution can be applied as a tissue cooling method in rhinoplasty and in several other surgical procedures. 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 .

Favorable Outcome with Close Margins in Patients Undergoing Nipple/Skin Sparing Mastectomy with Immediate Breast Reconstruction: 5-year Follow-up.

BACKGROUND: Implant-based breast reconstruction after mastectomy has recently been reported to be the preferred type of surgery among breast-specific surgeons and plastic surgeons. AIMS: To explore the significant clinicopathological factors associated with long-term outcome related to local recurrences of the nipple among patients who underwent immediate breast reconstruction with tissue expander or implant after mastectomy. STUDY DESIGN: Retrospective cohort. METHODS: From January 2007 to January 2013, 51 breast cancer patients who underwent immediate breast reconstruction with tissue expander or implant were retrospectively analysed. Patients' demographic data, clinicopathological characteristics, and clinical outcome by disease-free survival and disease-specific survival analyses were determined. RESULTS: The median follow-up was 64 (31-114) months. Of the 57 mastectomies, 41 were skin sparing mastectomy (72%) and 16 were nipple-areola sparing mastectomy (28%). Immediate breast reconstruction surgery included tissue expander (n=46, 81%) or implant (n=11, 19%) placement. The molecular subgroups of 47 invasive cancers were as follows: luminal A (n=23, 49%), luminal B (n=16, 34%), non-luminal HER2 (n=5, 10.6), triple negative breast cancer (n=3, 6.4%). The 5-years disease-specific survival, disease-free survival, and locoregional recurrence-free survival rates were 96.8%, 90%, and 97.6% respectively. Patients with luminal A cancer were found to have an improved 5-year disease-free survival time than other (luminal A; 100% vs. non-luminal A; 78%; p=0.028). Of the 14 nipple-areola sparing mastectomy, 13 had a close median tumour distance to nipple-areola complex (<20 mm) with a 5-year locoregional recurrence free survival of 100%. CONCLUSION: Immediate breast reconstruction with implant or tissue expander can be safely applied in patients undergoing skin sparing mastectomy or nipple-areola sparing mastectomy. Patients with luminal-A type show the most favourable outcome. During the 5-year follow-up period, patients even with close margins (<20 mm) to nipple-areola complex with nipple-areola sparing mastectomy have excellent locoregional and overall survival when treated by contemporary multidisciplinary oncological management.

Monobloc Reconstruction of Dome, Medial Crura, and Columella with Gamma-Shaped Costal Cartilage Graft.

In severe nasal deformities, the original cartilages are removed, or they become unusable because of previous operations. Costal cartilage (CC) is one of the most important tools for the replacement of deficient nasal osteocartilaginous framework. In 4 secondary and 1 tertiary rhinoplasty cases with severe deformities of medial and lateral crura of the lower lateral cartilages, we have prepared a long strut graft from a CC and then split the graft tip 5-6 mm vertically into 2 equal halves to create a gamma (ϒ)-shaped strut graft. We have sutured the base of this graft to the nasal spine and/or the bases of the medial crural remnants. Then, we have prepared lateral crural grafts and secured the grafts over lateral crural remnants. Then we curved the split tip winglets of the ϒ-shaped strut graft to both sides and sutured them to lateral crural grafts in order to create a new dome. Splitting of the CC strut graft reduces the need for extensive suturing at the tip, obtains smoother contours and ensures graft economy, and provides an original and stable dome shape. The bending capacity of the CC is limited in middle-aged patients. Costal allografts from a young cadaver can be a good alternative. ϒ-shaped costal crural graft is useful for medial crural and domal monobloc reconstruction in secondary and tertiary cases.

Analyses and classification of complexities in rhinoplasties based on factors increasing the difficulty and their appropriate reconstruction.

OBJECTIVES: This study aims to classify the factors that make rhinoplasty difficult and appropriate reconstruction of it. PATIENTS AND METHODS: We retrospectively evaluated the records of 103 patients who underwent rhinoplasty at our private clinic between April 2002 and December 2014. The most important reagent affecting the degree of difficulty in our study was the adhesion of the bone and cartilaginous structures to the skin and mucosa, as an outcome of on previous operations. Structural deficiencies in various parts of bone and cartilaginous structures, presence of septum deviation at a very advanced level, asymmetries in the lower and upper lateral cartilages, fracture deformities or trauma-related bone compressions, skin quality and thickness and the age of the patient were other criteria that affected the degree of difficulty of rhinoplasty. Taking these compelling factors into consideration, a difficulty coefficient table was set up with a new classification that determines complexity and suggests appropriate reconstructions. RESULTS: The total of difficulty coefficients of rhinoplasties between 1-3 were considered to be less complex, those between 4-6 as intermediate complex and those being >7 as very complex rhinoplasty. CONCLUSION: Calculation of the difficulty coefficient provides objective determination of the degree of difficulty of the operation. Reconstruction plans, probable duration of surgery, preoperative preparations, all grafts and materials considered for use may be predicted according to the difficulty coefficient. The surgeon can test whether his or her experience is sufficient or not according to the difficulty coefficient. Surgical risks can be assessed in the light of the difficulty coefficient and shared with the patient.

Intralesional application of epidermal growth factor in limb-threatening ischemic diabetic foot ulcers.

OBJECTIVE: The intralesional injection of recombinant human epidermal growth factor (EGF-IL), a new therapy, has been claimed to prevent major amputations in advanced diabetic foot lesions. In this study, the efficacy of EGF-IL on advanced diabetic foot ulcers (DFU) was reviewed. METHODS: Intralesional 75 µg EGF application (Heberprot-P® 75, Heber Biotec, Havana, Cuba) to 12 diabetic foot lesions in 11 patients (8 males, 3 females; mean age: 62.2±10.6 years) was evaluated. Most of the patients had undergone revascularization and received hyperbaric oxygen therapy (HBOT) and negative pressure wound therapy (NPWT), along with standard care, but failed to heal. After amputation was offered as the final option, EGF-IL was applied to evaluate its effects. RESULTS: Two patients underwent amputation, while 10 lesions of the remaining 9 patients healed completely. CONCLUSION: Our results prove that intralesional application of EGF can prevent amputations in advanced diabetic foot cases with an ischemic component. However, evidence in the literature supporting its use remains lacking, and its high cost presents an additional problem. Thus, we believe that intralesional application of EGF should be an option for ischemic wounds only after vascular evaluation (and intervention when possible), HBOT, NPWT, and standard care have proven insufficient.

Optimal treatment of zygomatic fractures: a single-center study results.

OBJECTIVES: This study aims to investigate the epidemiological and operative characteristics of patients undergoing surgery for zygomatic fractures. PATIENTS AND METHODS: Between May 2008 and October 2013, a total of 121 patients (98 males, 23 females; mean age 27 years; range, 9 to 63 years) who were operated for zygomatic fractures in our clinic were retrospectively analyzed. Age and sex of the patients, symptoms, fracture and incision sites, length of hospital stay, plate type, treatment options, and complications were recorded. RESULTS: Assault was the leading cause of trauma (39%), followed by traffic accidents (24%). The most common symptom or clinical sign was the periorbital ecchymosis/hematoma. Conservative treatment was applied in 14 patients (12%). Surgery was performed with a closed reduction in 17 patients (14%) and open reduction in 90 patients (74%). The most common fracture site was the infraorbital rim in 76 patients (62.8%). A total of 48% patients had three-site, 35% had two-site and 12% had one-site of fixations. The major material used for the orbital floor reconstruction was porous polyethylene in 43.7% patients. CONCLUSION: Our study results show that surgery is required in the majority of the patients with zygomatic fractures. However, further large studies are required to determine many parameters such as incision sites, plate locations, and the material to be used in orbital floor reconstruction.

Management of soft tissue extremity degloving injuries with full-thickness grafts obtained from the avulsed flap.

BACKGROUND: A "degloving injury" is referred to as seperation of cutaneous tissue from the deeper structures of the body. Although many methods have been defined to reform the tissue integrity; defatting and readaptation of the avulsed flap still comprises one of the most effective methods. METHODS: From 2000-2012, we treated a total of nine patients with avulsed extremities with defatting and readaptation of the same flap. The fat compartment of the flaps was removed and the skin was meshed. The patients were followed-up with for an average of 12 months (range: 8-18 months). RESULTS: Total closure of the defect and healing was achieved in seven patients. Although 30% of the total surface area of the graft was lost in one patient, and 10% in another, total epithelialization was achieved later with secondary grafting. CONCLUSION: Defatting, meshing and readaptation of the same flap to its original site is still a valuable option for avulsion injuries because of the relative ease of the procedure, shorter operative times, and usability of the procedure by general surgeons. This technique might be particularly important in places where a reconstructive plastic surgeon is not available.

Using a capsule flap for the reconstruction of a partial auricular defect.

In this article we describe the capsular flap for covering the posterior surface of cartilaginous framework in ear reconstruction. This technique has not been previously described in the published literature.

A device for the functional improvement of lagophthalmos.

A new device was tested on rabbits for the improvement of lagophthalmos, which causes dryness and irritation of the eye and may cause blindness if untreated. In the presented study, 14 rabbits were injected with local anesthetic to induce temporary facial palsy leading to lagophthalmos on one side. To provide functionality to the upper eyelids, ferromagnetic steel plates were either implanted within the eyelid or taped on the eyelid surface. The device detected blinking in the nonparalytic side and moved the anesthetized paralytic eyelid by pulling the steel plate electromagnetically. The control group (n = 5) did not wear the device, and they could not shut their paralytic eyelids. The treatment group with the external placement of the metal plate (n = 4) and the treatment group with the implant (n = 5) wore the device for artificial blinking. All animals were observed during the experiments, and blinking was recorded on digital video. The data collected from video records were analyzed to test the statistical difference of blinking between control and the treated groups. The results showed that the treatment groups could artificially move their paralytic eyelids. Furthermore, the treatment group with the implant showed a noticeable similarity in eyelid position compared with healthy (nonparalytic) eyes.

Cosmetic closure of pilonidal sinus defects with bilateral transpositional adipofascial flaps.

The optimal treatment of the pilonidal sinus has not currently been defined. This study described the use of a modified bilateral transpositional adipofascial flap technique that effectively serves to flatten the deep natal cleft while keeping the scar limited to the intergluteal fold for good cosmesis. Between June 2007 and September 2011, 83 patients (61 men, 22 women) were included in the study. Duration of pilonidal sinus symptoms ranged from 1-15 (median 5) years; 15 patients had recurrent disease. Before the operation, perforating branches of the four pairs of lateral sacral arteries were identified with a Doppler audioscope. After complete excision of the sinus cavity and adequate undermining of the skin, bilateral adipofascial flaps were raised in order to realise a Yin-Yang pattern, with the lateral sacral artery perforators at the base of each flap. Complementary flaps were then transposed into the defect and inset to completely obliterate dead space. Skin was closed primarily in two layers. The median (range) defect size after total excision of the sinus cavity was 38 (19-60) cm2. All flaps survived. There was no wound infection or dehiscense. Median (range) follow-up was 26 (6-52) months. No recurrences were observed. Extensive scarring or asymmetry in the gluteal prominences was not observed. Transient paraesthesia over the flap donor region occurred in 14 cases (16%) and resolved completely within 6 months. The bilateral adipofascial transpositional flap method is an alternative to previously described treatment options in pilonidal sinus surgery. It is a safe, reliable, and easily applicable method, which provides cosmetically acceptable coverage of pilonidal sinus defects of moderate size.