Medial sural artery perforator flap in head and neck reconstruction.

Medial sural artery perforator (MSAP) flap is a relatively new flap which is a modification of medial gastrocnemius myocutaneous flap. Both radial forearm flap and MSAP has common benefits, such as thinness, long pedicle and pliability; however, MSAP has lower donor site morbidity when compared with radial forearm flap. Because of this reason, the MSAP flap has gained popularity during the last decade. The objective of this study was to determine clinical application results of this flap in reconstruction of post-oncologic defects in the head and neck region. 11 patients operated for head and neck post oncologic defects and reconstructed with MSAP between June 2014 and Dec 2015 were included in the study. Age, gender, histopathology, area of reconstruction, flap size, number of perforators were reviewed. Postoperatively recipient and donor site complications, hospital stay and additional surgical procedures were also analyzed. We had seven uncomplicated cases; one total flap failure due to arterial problem, in three cases due fistula formation and local wound healing problems additional surgeries were performed. All venous anastomosis were performed with 9/0 sutures, nine arterial anastomosis were performed with 9/0 and two arterial anastomosis were performed with 10/0 nylon sutures. Medial sural artery perforator flap is a good alternative in head and neck reconstruction, with the advantages of thin and pliable skin, a reliable vascular pedicle, straightforward intramuscular dissection. But there are certain drawbacks like tedious pedicle and perforator dissection, small arterial pedicle size which complicates anastomosis and obscurities of anatomy. Surgical team must always be ready for a difficult micro anastomosis and an alternative flap choice must be prepared and counseled with the patient in case of inadequate perforators.

Repairing peripheral nerve defects by vein grafts filled with adipose tissue derived stromal vascular fraction: an experimental study in rats.

BACKGROUND: There are many studies in the literature combining vein grafts with cell cultures, muscle, tendon, and nerve tissues, but none of them could replace isolated nerve grafts for nerve repair in clinical settings. There are studies in the literature indicating that adipose tissue derived stromal vascular fraction (SVF) enhances peripheral nerve healing. Considering these facts, an experimental study was performed in rats based on combining SVF with vein grafts for peripheral nerve defect repairs. METHODS: The study included 30 rats which were divided in three groups. In the first stage, an 8 mm nerve defect was created in tibial nerve of each rat. In Group 1, the defect was reconstructed with nerve graft, in Group 2, the defect was reconstructed with vein graft, and in Group 3, the defect was reconstructed with vein graft filled with SVF solution. After 3 months, the second surgical stage was performed and nerve biopsies were taken. Tissue samples were observed histopathologically. RESULTS: There were no statistically meaningful difference between nerve grafts, vein grafts and adipose tissue derived SVF- vein grafts combination groups considering myelin diameter and axonal diameter. Axon count was statistically superior in the nerve graft and study groups when compared to empty vein groups. CONCLUSION: In conclusion, our results support the usage of stromal vascular fraction-vein graft combination for peripheral nerve defect repairs.

A Retrospective 3D Radiologic Analysis of 52 Patients with Mandible Fractures.

When fractured, mandible angulates. For better preoperative evaluation, movements of fractured mandibular segments should be documented in x-, y-, and z-axes. This article quantitatively evaluates the pattern and degree of the angulation. Fifty-two patients with mandible fractures were involved in this study. After defining a three-dimensional (3D) coordination system consisting of the x-axis (the axis directed from the medial to lateral side of the skull), y-axis (directed from the inferior to superior side), and z-axis (directed from the posterior to anterior side), the degree with which the fractured mandible angulated around each of these axes was measured using 3D graphic software. The tendency of the angulation was compared between the three axes. Frequency of complications, operation times, maxilla mandibular fixation (MMF) need, and epidemiologic data were compared with the angulation results. Angulation around the x-axis was the most frequent with a 55.8% incidence, followed by a substantial margin of angulation around the y-axis with a 21.2% incidence; angulation around the z-axis was rare, with an incidence of 15.4%. Furthermore, the degree of z-axis angulation was minor compared with x- and y-axes angulations. There were statistically increased rate of complications, operation time, and MMF need in patients with more than 10 degrees of angulation in any case. Operation time and complication rates are also increased in patients with internal rotation of the proximal segment. Preoperative evaluation of mandible fracture angulation degree is useful for determining postoperative complication rates, MMF need, and operative challenge. This finding is helpful for effective performance to reposition the fractured mandible.

Bilaterally Symmetrical Lower Extremity Compartment Syndrome following Massive Transfusion.

Compartment syndrome is a serious condition characterized by raised intracompartmental pressure, which develops following trauma. Well leg compartment syndrome (WLCS) is a term reserved for compartment syndrome in a nontraumatic setting, usually resulting from prolonged lithotomy position during surgery. In literature, 8 cases have been reported regarding well leg compartment syndrome in a supine position and bilateral symmetrical involvement was observed in only 2 cases. In WLCS etiology, lengthy surgery, lengthy hypotension, and extremity malpositioning have been held responsible but one of the factors with a role in the etiology may have been the tissue oedema and impaired microcirculation formed from the effect of vasoactive mediators expressed into the circulation associated with the massive blood transfusion. The case is presented here regarding symmetrical lower extremity compartment syndrome after surgery in which massive transfusion was made for gross haemorrhage from an abdominal injury. In conclusion, blood transfusion applied at the required time is life-saving but potential risks must always be considered.

The Effect of Botox on the Implant Stabilization and Capsular Formation: An Experimental Study.

BACKGROUND: Breast augmentation is one of the most common esthetic procedures with increasing frequency throughout the past years. The most demanding complications involving esthetic and reconstructive breast surgery are the malpositioning of the implant and capsular contracture. The etiology, prevention, and management remain to be fully explained. Botulinum toxin (BTX) administration has anti-inflammatory effects that can possibly decrease capsular contracture, and chemical denervation of the pectoral muscle theoretically may decrease incidence of malrotation. In our literature search, we found only 1 clinical study using BTX A for capsular contraction, and there were no experimental studies about the implant stabilization and capsular contracture. Therefore, we have studied the effect of BTX A on the prevention of breast implant malrotation and capsular contracture in a rabbit model. METHODS: Sixteen smooth-surfaced cohesive gel implants were implanted in 8 New Zealand white rabbits. The backs of the rabbits were divided into 2 groups. After skin incision, the exposed latissimus dorsi muscle was elevated, and a submuscular pocket was made. In the experimental group, Botox was injected in the muscle overlying the implant. In the control group, the implants were placed under the muscle, and saline was injected into the muscle. At the end of 3 months, the rabbits were imaged and evaluated by ultrasonography and x-ray to examine capsule formations and the movement of the implants. The animals were killed, and the implants with peri-implant capsule were excised. We evaluated collagen pattern and capsule thickness on ventral, lateral, and dorsal aspects. RESULTS: The Botox group showed less infiltration of inflammatory cells at the third month (P < 0.05). Statistically significant differences in capsular thickness were observed on histopathological examination and ultrasonographic imaging. The capsule was thinner on all aspects and the collagen pattern had a more parallel alignment at low density in the experimental group compared with the control group. With x-ray, we observed an increased lateral movement of the implants in the control group. CONCLUSIONS: The use of Botox effectively decreased implant movement and capsular formation at 12 weeks. More experimental and clinical studies will be required to determine whether this is a durable result that can be reproduced in humans.

Nasal glioma presenting with strabismus.

Congenital midline nasal masses are rare anomalies that occur in about 1 in 20,000 to 40,000 live births. Nasal gliomas are thought to be collections of heterotopic tissue of neurogenic origin, which have lost their intracranial connection. It rarely cause ocular distortion and deformity in the medial orbital wall. We describe here a case of a 12-month-old baby girl diagnosed as extranasal glioma at the lateral nasal wall and medial orbital wall presenting with strabismus and subsequently treated in our service and perform a literature review.

Penile strangulation and necrosis due to condom catheter.

Condom catheters are often used in the management of male urinary incontinence, and are considered to be safe. As condom catheters are placed on the male genitalia, sometimes adequate care is not taken after placement owing to poor medical care of debilitated patients and feelings of embarrassment and shame. Similarly, sometimes the correct size of penile sheath is not used. Strangulation of penis due to condom catheter is a rare condition; only few such cases have been reported in the literature. Proper application and routine care of condom catheters are important in preventing this devastating complication especially in a neurologically debilitated population. We present a case of penile necrosis due to condom catheter. We will also discuss proper catheter care and treatment of possible complications.

A Clinical Comparison of EMLA Cream and Ethyl Chloride Spray Application for Pain Relief of Forehead Botulinum Toxin Injection.

OBJECTIVES: This study aims to analyze the efficiency of EMLA cream and ethyl chloride spray application for pain alleviation before botulinum toxin injection. METHODS: Forty-five patients were divided into 3 treatment groups. Skin cooling with ethyl chloride spray (in group 1), topical anesthetic cream (EMLA) (in group 2), was used on the forehead area on one side previous to injection; the opposite side served as the control. In the third group (n = 15), cold was applied using ethyl chloride spray to one side, and to the other side topical anesthetic cream (EMLA) was applied. A visual analog scale was used for pain intensity. RESULTS: In the first group, the average pain score was 3.20 ± 1.20 on the side where ethyl chloride spray was applied and 7.26 ± 1.94 on the control side (P < 0.05). It was 4.20 ± 1.37 on the side receiving EMLA and 7.66 ± 1.54 (P < 0.05) on the control side in the second group. In the third group, the average score was 6.80 ± 1.37 for the EMLA side and 2.93 ± 1.03 for the ethyl chloride sprayed side (P < 0.05). CONCLUSIONS: Skin cooling with ethyl chloride spray significantly decreases the pain associated during forehead botulinum toxin injections.

The effects of botulinum toxin A on the wound and skin graft contraction.

OBJECTIVE: In the current study, we investigated the efficiency of botulinum toxin-A (BTX-A) on wound and skin graft contractions. METHODS: Thirty adult female Wistar rats weighing 150 to 200 g were used. The rats were divided into 2 groups. As each rat in these groups underwent 2 different procedures, those groups also were divided into 2 subgroups. Group 1 (n = 15) was assigned as the control group. Pair of full-thickness skin grafts of 40 × 20 mm was harvested from the 2 sides of the dorsal regions of the rats. The full-thickness skin graft harvested from the left side was readapted (Group 1A), and the right side was left as an open wound (Group 1B). The rats in the second group (n = 15) underwent the same procedures and botulinum toxin-A (BTX-A) 0.5-international unit injection to the graft area (Group 2A) and open wound area (Group 2B). RESULTS: A decrease in the amount of the contraction was observed in the groups, which underwent BTX-A injection. In the histologic examination, it was observed that inflammation and collagen amount was higher, and the arrangement of the collagen was different in the groups, which underwent BTX-A injection. CONCLUSIONS: It has been determined that BTX-A injection reduces wound and graft contraction, and also, it is effective on reducing the amount of sebaceous cells and hair follicles.

Versajet hydrosurgery system in the debridement of skin necrosis after Ca gluconate extravasation: report of 9 infantile cases.

OBJECTIVE: The aim of the study was to evaluate the results of debridement with Versajet hydrosurgery system in patients with skin necrosis after ca gluconate extravasation. METHODS: We evaluated nine infants (mean age: 26 days; range: 1 day to 3 months) with calcium gluconate extravasation injury. Site of injury was the foot in 3 cases, the hand and wrist in 5 and the scalp in one. In all patients the skin necrosis was debrided with Versajet hydrosurgery system under general anesthesia without damaging the dermis layer. RESULTS: Following debridement all wounds healed spontaneously by re-epithelization and the mean time of full epithelization was fourteen days. No patient required a second debridement. At a minimum follow-up of 1 year minimal scar formation was noted and there was no hypertrophic scar. CONCLUSION: Versajet hydrosurgery system appears to be effective in the debridement of skin necrosis due to ca gluconate extravasation in pediatric population.

A hydrosurgery system (Versajet) with and without hydrogen peroxide solutions for the debridement of subacute and chronic wounds: a comparative study with hydrodebridement.

OBJECTIVE: The aim of this study was to evaluate the efficacy of hydrosurgery prepared with or without hydrogen peroxide for the management of subacute and chronic wounds. METHODS: This is a retrospective study on patients with infected subacute and chronic wounds. The wounds were debrided using hydrosurgery prepared with (the study group) or without hydrogen peroxide before grafting the wound (the control group). RESULTS: There were 60 patients in the study group and 70 patients in the control group. The hospital stay (mean, 7.83 [SD, 2.16] vs 9.86 [SD, 3.41] days; P < .001) and graft viability (mean, 3 [2-3] vs 2 [2-3]; P = .001) were significantly better in the study group than in the control group. The difference of hemoglobin levels after surgery was also significantly lower in the study group (0.1 [0-0.48] vs 0.45 [0-1]; P = .004). CONCLUSIONS: Encouraging results were obtained with the use of the hydrosurgery system prepared with hydrogen peroxide for infected subacute and chronic wounds. This method decreased hospital stay and bleeding, thus providing better contact of the skin graft with the wound bed, allowing early rehabilitation. The findings of the authors' study need to be substantiated in large-scale randomized controlled trials.

Unusual burn injury due to application of white vinegar and aspirin mixture.

Traditional medicine remedies are believed to provide relief from pain; nevertheless, it can be a risky procedure if these remedies are prepared inappropriately. Here, we describe a patient who suffered from a split-thickness leg burn after applying a self-inflicted mixture consisting of white vinegar and aspirin prepared for knee pain. This case report highlights a rare cause of a chemical burn that could become more common with increasing use of traditional remedies worldwide.

Using bilaterally fascioperichondrial flaps with a distal and a proximal base combined with conventional otoplasty.

Prominent ears are the most common aesthetic abnormality of the external ear. Mustardè sutures and conchal setback are usually used for otoplasty, additional various cartilage-manipulation methods are also presented. One adjunctive technique that is often used involves the elevation of a fascial flap beneath which is sutured for additional cover, potentially reducing the risk of complications and recurrence. In the literature, this flap is traditionally raised with a proximal or distal base but it can be raised both distally and proximally with a number of advantages as we demonstrate. This article presents a technique to raise the fascioperichondrial flap with both a proximal and a distal base as an addition to conventional otoplasty. One hundred consecutive patients, followed up for at least 12 months, have been reviewed. One hundred ninety otoplasties were performed in 100 patients (10 unilateral), 65 women and 35 men. The mean age was 20.6 years, and the mean follow-up time was 16.3 months, respectively. No patient has developed skin necrosis or suture extrusion. In two patients (One bilateral and one unilateral for a total of three ears) a further procedure has been required to improve symmetry (1.5%). Using the retro auricular fascioperichondrial flap combined with other techniques offers good results and can be used as a standard procedure in the surgical treatment of prominent ears.

Rare complication after VAC therapy in the treatment of tissue defect due to surgical excision of pilonidal sinus.

BACKGROUND: Pilonidal sinus is frequently managed with surgical incision. If the wound is left open to heal by secondary intention, negative pressure wound therapy (NPWT) is often used to promote healing. CASE: We describe the case of a 60-year-old patient referred after excision of a pilonidal sinus, which was managed postoperatively with NPWT. Unfortunately, the patient developed squamous cell carcinoma, which was undetected postoperatively, as the dressing was left in place for 5 days. CONCLUSION: Guidelines for the use of NPWT should be followed, with dressing intervals at 2 to 3 days. Wounds managed by NPWT should be monitored carefully for malignancy at the time of dressing changes.

2-octyl-cyanoacrylate glue for fixation of STSG in genitourinary tissue defects due to Fournier gangrene: a preliminary trial.

BACKGROUND: In these reported cases, we observed the outcomes of skin take and wound healing using 2-octyl-cyanoacrylate glue, which was used as tissue glue in the reconstruction of complex genital skin loss due to fournier gangrene. METHODS: Fifteen patients with Fournier's gangrene were treated in this study. After initial surgical debridement, all defects were repaired using STSG. In this method a thin layer of 2-octyl-cyanoacrylate was dripped on the recipient site immediately before graft application. All wounds were followed up postoperatively and observed for evidence of graft take, seroma or hematoma formation, drainage, and infection. Patient and physician satisfaction were also determined. RESULTS: Grafts were completely accepted in all fifteen patients. None of the patients had wound infection, seroma, hematoma, or other complications. CONCLUSION: Use of 2-octyl-cyanoacrylate glue (Glueseal) for STSG fixation in complex genital skin defects after Fournier gangrene may be an acceptable alternative to conventional surgical closure with a good cosmetic outcome. Further studies are needed to confirm our initial success with this approach.

Comparing reduction mammaplasty specimens between superior and central pedicle techniques: a retrospective study.

UNLABELLED: The aim of this study was to evaluate the histologic diagnoses of the reduction mammaplasty specimens in two retrospective series of patients operated using superior and central pedicle mammaplasties. Between November 2000 and December 2011, 60 consecutive patients (120 breasts) underwent breast reduction using the superior pedicle technique with a vertical scar (Lejour's technique). These patients were compared with another series of 80 patients (150 breasts) who underwent breast reduction using a vertical scar mammaplasty with a central pedicle (Copcu's technique). The characteristics of the patients were statistically similar between the two groups. Therefore, 140 patients who had undergone reduction mammaplasty were analyzed with respect to their histologic diagnoses, age, and specimen's weight. In the superior pedicle technique, we found that 30% of these women had pathologic alterations in at least one of their breasts, whereas the pathologic changes in patients who underwent Copcu's technique were 35%. In terms of tumor diagnosis, the upper quadrant excision technique (e.g. Copcu's method) may be safer. If there is no other special condition, it is better to use the pedicle technique in which the upper lateral and upper medial pole is removed. LEVEL OF EVIDENCE: Level I, therapeutic study.