Moist heat postconditioning to increase flap survival.

One of the areas of interest within the discipline of reconstructive microsurgery is increasing the amount of tissue harvested along with a given pedicle and sustaining it. The aim of this study is to introduce moist heat postconditioning as a means to increase skin flap survival and evaluate its effectiveness. Eight white New Zealand rabbits weighing 2500 to 3000 g were separated into two groups. In both groups, the truncal flaps spanning four consecutive angiosomes were elevated bilaterally. Flaps were inset back afterwards, and to the flaps in the trial group moist heat was applied for 30 minutes. After 2 weeks, the flaps were photographed and flap survival ratios were calculated via ImageTool© software (University of Texas Health Science Center, San Antonio, Texas, USA). With an average necrosis ratio of 4.91% versus 37.31%, the flaps treated with moist heat displayed a significantly better survival rate (p = 0.000). This study presenting our new method demonstrates that application of moderate moist heat right after the flap inset provides a significant increase in flap survival and introduces a noninvasive, cost-effective, and safe method for clinical use.

The effect of "minimally invasive transfer of angiosomes" on vascularization of prefabricated/prelaminated tissues.

Prefabrication and prelamination are experimental and clinical applications of reconstructive surgery and inspired the vascularization challenge of engineered tissues. The purpose of this study is to test the efficiency of "minimally invasive transfer of angiosomes" to enhance the vascularization of the final construct during prefabrication and prelamination. Fifteen rabbits were used for this study. Three of the animals were used in a pilot study to develop the protocol. During the study, thoracodorsal and lateral thoracic vascular pedicles on each side constituted 4 study groups. The pedicles were prepared to simulate prelamination with and without transfer of angiosomes, and prefabrication with and without transfer of angiosomes. In all of the groups, a 10 x 15 mm auricular cartilage graft was used as the construct to be vascularized. After 2 weeks, vascularization of the grafts was evaluated by means of microangiography and histology. Results indicate that both prelamination and prefabrication with transfer of angiosomes displayed better vascularization, both qualitatively and quantitatively. However, prelamination with transfer of angiosomes group displayed distinct statistical superiority. The results suggest that minimally invasive transfer of angiosomes coupled with the procedure significantly increases the induction of angiogenesis during prelamination and prefabrication.

The effect of autogenous vein grafts on nerve repair with size discrepancy in rats: an electrophysiological and stereological analysis.

Aside from anatomical repairs, the reestablishment of sensory and motor innervations for proper functional recovery is one of the fundamental objectives of reconstructive surgery. The heterotopic transfer of autologous tissues is likely to result in a size discrepancy between the donor and recipient nerves, which will have a negative influence on regeneration. Twenty Wistar albino female rats were used in a study that was divided into two main groups: tibial-peroneal (TP) and peroneal-tibial repair (PT). Both types of nerves were exposed on the hind legs with the nerves cut on the right side, while the proximal stump of the tibial nerve and distal stump of the peroneal nerve were sutured to each other. These groups are also called end-to-end neurorrhaphy groups (EtoE). On the left side, the tibial and peroneal nerves were cut on the same level as on the right side. After the end-to-end epineural suturing of the nerve, the vein graft was slid over to the repair zone under irrigation. These are called the vein graft group (VG). All processes mentioned above were also done for the PT group. On the 90th postoperative day, anesthetized animals were fixed prone on a board, with the nerves carefully dissected for electrophysiological recording. Stereological methods for an estimation of the total number of myelinated fiber, a mean axonal cross-section area and the thickness of the myelin sheet were used. In TP and PT groups, nerve conduction velocities were found to be higher within the VG group. Nevertheless; the difference was only significant in the PT group. In both TP and PT groups, the increase in the axon number, axon area and myelin thickness were statistically different in favor of the vein graft sides. An appearance of vacuoles and degenerated pertinacious material within the myelin sheath of EtoE sides was seen. A histomorphological examination of the sections proximal to, from, and distal to the repair zone over three months revealed less epineural scarring, a thinner epineurium, more regenerated axons and fewer inflammatory cells in groups where vein grafting was used, because the vein graft provided additional mechanical and chemical support in the size discrepancy of the nerve regeneration.

Influence of diabetes on critical flaps based on the vascular axis of a sensory nerve.

Delayed sural flap based on the vascular axis of the sural nerve has been advocated for coverage of diabetic foot ulcers. In this study we compared the survival of neurovenous and standard inferior epigastric island flaps in diabetic and non-diabetic rats. VEGF concentrations and electrolyte balance of the flaps were also investigated during elevation and on the fifth day to explore the possible mechanisms that influence ischaemia of the flap during the hyperglycaemic state. There were no statistical differences in area surviving between diabetic and control rats for either flap. The VEGF concentrations were also similar in the two flaps in the two groups during elevation. On the fifth day, VEGF concentrations had decreased significantly in all of the flaps. Electrolyte balance paralleled VEGF concentrations. We conclude that flaps based on the vascular axis of a superficial nerve deserve further experimental and clinical attention as potential options for reconstruction of ulcers on diabetic feet.

The Amazons and an analysis of breast mutilation from a plastic surgeon's perspective.

BACKGROUND: The Amazon philosophy has been increasing in popularity because of the evolving status of women in society. Many references point to Themiscrya on the southern coast of the Black Sea in Anatolia as the Amazon homeland. The primary objective of this article is to discuss the different femininity of the Amazons and their breast mutilation from the perspective of a plastic surgeon who has been living in this region that the Amazons inhabited. METHODS: Findings from archaeology, linguistics, anthropology, medicine, history, psychology, and the fine arts were integrated. RESULTS: The hypotheses that have been proposed to explain the method of breast mutilation include amputation, cauterization, breast searing, and breast pinching. It is generally believed that the primary purpose was to facilitate the efficient use of a bow. Another explanation would be that breast mutilation was performed for medical reasons, including the prevention of breast pain, the development of a tender lump, or cancer. There is another school of thought on this involving religious and sociological reasons that breast mutilation was a badge of honor for warrior women and a sign that a woman had become a real warrior and a sacrifice to Artemis as a sign of service. CONCLUSIONS: Much indirect proof and archaeological evidence point to their historical existence. The Amazons, who lived in an autonomous and original social model, changed their image and function to suit the needs of the society and the times.

A simple and effective procedure for treating burn contractures: releasing incision and quadra Z technique.

Burn contractures particularly involving the joints are challenging problems which might cause severe functional impairments. Many surgical techniques have been described for use, however, an ideal method yet to be found. Releasing incision is the most common and effective way to release the wide and severe contractures but it has some drawbacks. We propose a releasing incision technique combined with four Z plasty incisions to overcome the disadvantages of traditional releasing incision technique. We successfully used our releasing incision and quadra Z technique on seven consecutive patients with burn contractures between 2003 and 2005. We modified the classical releasing incision technique by adding four Z plasties; two of them with a common base on each corner of the incision line. In this technique, limitation of the webbing following the incision is made possible by the transposed flaps and unnecessary lateral extension of the incision and the defect was avoided, i.e. maximum release gain with minimal defect was provided. Satisfactory results were achieved in seven patients treated with this technique due to significant burn contractures between 2003 and 2005 with no significant complication. We propose this technique is suitable in all patients with severe burn contractures who require releasing incision and grafting.

Oblique scapular flap.

We report an axial transposition flap based on the anterior branch of the descending branch of the circumflex scapular artery. This has some advantages, including a hidden donor site, easy transfer with no abnormalities, no distortion of the structures, and much pliable tissue.

The effect of twisting on perforator flap viability: an experimental study in rats.

Perforator flaps increasingly find acceptance and use in the field of reconstructive surgery due to their decreased donor-site morbidity and increased like-tissue coverage. Nevertheless, they are more prone to vascular compromise, especially when the meticulous technique they require is not employed. Pedicle twisting is a condition occasionally encountered in flap procedures, sometimes inadvertently, sometimes inevitably. In this study, circulatory comprise induced by twisting of the pedicle on a true perforator flap in a rat model is investigated.Thirty-eight Wistar-Albino rats were randomized into 4 groups, and cranial epigastric artery true perforator flaps were elevated on a single perforator. The flaps were returned as they were in the control group (n = 9), and with 90 degrees , 180 degrees , and 270 degrees of torsion in groups 2 (n = 9), 3 (n = 10), and 4 (n = 10), respectively. The flaps were evaluated by their flap survival area, weight, and histopathological appearance by the end of the first week. The mean flap survival ratios for groups 1, 2, 3, and 4 were 97.78 +/- 4.41%, 72.22 +/- 44.10%, 73.50 +/- 30.46%, and 30 +/- 30.18% (mean +/- SD), respectively. The degree of degenerative changes in group 4 was found to be statistically significant (P < 0.016).Our histopathological examinations indicate that vascular compromise was moderate in group 3 and severe in group 4. Our findings suggest that under normal conditions, the pedicle of a true perforator flap must not be twisted more than 180 degrees .

A perichondrial flap for functional purposes in rhinoplasty.

Recent trends in rhinoplasty techniques have focused on anatomic repair as well as respect and preservation of soft tissue integrity. In this article, the authors describe the use of a perichondrial flap, then discuss technical considerations and clinical perspectives of their advantages. A perichondrial flap helps to restore the stability of the upper lateral cartilage, to achieve extra padding, and to secure osteocartilagenous grafts. The method described has been used for 60 consecutive patients. The majority of these patients were satisfied with the results. To obtain detailed information about the perichondrial flap, the authors performed an anatomic study of 13 cadavers. The average thickness of the perichondrium was 186+/-146.1 microm (range, 90--596 microm). On the basis of the results, it was concluded that elevation of the perichondrial flap with loupe magnification could improve the outcome of rhinoplasty.

Longitudinally-split radial forearm flap.

We have applied the split flap concept to a distally-pedicled radial forearm flap to cover separate dorsal defects of the fingers in two cases. The rationale is that there are the vascular plexuses inside and around the sensory nerve that permit surgical splitting of the flap. In the split design, the first segment is supplied by the radial artery itself. The second segment is supplied by the neurocutaneous artery of the medial cutaneous nerve.

Botulinum toxin for the treatment of temporomandibular joint disk disfigurement: clinical experience.

Type A botulinum toxin was used for the treatment of symptoms of 26 patients (40 joints) with temporomandibular joint disk disfigurement. In all patients, 0.5 ml (12.5 U) was injected into the lateral pterygoid muscle. The temporalis, medial pterygoid, and masseter muscles were injected if severe tenderness was noted. The data were compared using the Wilcoxon signed rank test and the McNemar test. With the exception of clicking of the right joint, all mean outcome measures showed a significant difference between the preinjection and postinjection assessments. There was a significant difference between the preinjection and postinjection pain scores of the right joint (P=0.0019) and the left joint (P=0.000). Postinjection values of the mouth opening (P=0.002), subjective functional dysfunction (P=0.065), and clicking of the left joint (P=0.001) also showed a statistically significant difference from the preinjection values. In addition, the severity and frequency of headache were reduced after botulinum toxin-A injection into the lateral pterygoid muscle.

Compensatory brow asymmetry: anatomic study and clinical experience.

To obtain detailed information about the interdigitation between the frontalis muscle and the orbicularis oculi muscle, the authors performed an anatomic study involving 9 cadavers (17 specimens). Three types of interdigitation were recognized. Complete interdigitation was noted in 13 specimens, and partial interdigitation in 13 specimens. In one specimen, there was no interdigitation between the frontalis muscle and the orbicularis oculi muscle. Although most of the specimens showed complete interdigitation between the frontalis muscle and the orbicularis oculi muscle, the interdigitation area exhibited architectural heterogeneity. The study findings provide a basis for a better understanding of compensatory eyebrow ptosis. In addition, two cases supporting the theory that compensatory eyebrow asymmetry may resolve when the palpebral ptosis is treated are presented.

Spontaneous recanalization of the divided lactiferous duct in the rat.

The objectives of the current study were to test the hypotheses that ductus lactiferous may regenerate after its transection and to develop a reproducible model for future studies. A total of 168 nipples from 14 Wistar female rats were used in this experimental study. This study was conducted in 2 parts. During part 1, the normal anatomy of the lactiferous duct and its histomorphologic features were studied. This group was also used for histologic and morphometric comparison. During part 2, the lactiferous duct was exposed through a vertical incision and was transected by scissors. A small gap was produced by elastic retraction of the surrounding tissue. The authors assessed patency mainly by histologic evaluation. Galactography was performed to collect additional support for the recanalization process. The patency rate of the lactiferous ducts was 66.6%. Luminal narrowing was observed in all specimens. A significant difference did occur in the mean cross-sectional area (P < 0.01) and the wall thickness (P < 0.05) between 2 groups. A computed stereologic image analyzer was used to estimate the mean surface area of a lactiferous duct and the wall thickness.

Subcision surgery for the correction of ear deformities.

The authors report the application of subcision surgery to ear deformities for crosscutting and weakening of the deformed cartilage. The subcision techniques for correction of a deformed cartilage are divided into two groups. With the first method, termed "horizontal subcision," a 18-gauge needle is inserted horizontally through a puncture in the skin surface, and multiple passes are made. With the second method, termed "vertical subcision," a sweeping motion of the needle is used for crosscutting of the deformed cartilage. An experimental study was conducted using 10 rabbits (20 ears) to test the authors clinical observations. On the basis of histologic analysis, the authors hypothesized that with the horizontal subcision technique, the sharp edge of the needle damages the perichondrium and weakens the cartilage by creating multiple irregular microincisions. With regard to the vertical incision technique, gross examination showed partial or complete cuts of the cartilage. Subcision surgery was successfully used in eight cases.

Delay in neurovenous flaps: experimental and clinical experience.

The objective of this study was to examine the effects of the standard surgical delay in the flaps based on the cutaneous branches of the vascular axis around a superficial sensory nerve. The delay procedure was experimentally tested in rats and subsequently used in patients. In the experimental study, the survival of a delayed inferior epigastric neurovenous flap was compared with that of a nondelayed inferior epigastric neurovenous flap. One type of clinically applicable delay pattern (standard bipedicled technique) was employed. A 3 x 3 cm flap was raised in 20 female Wistar rats assigned randomly to 2 groups. Each group consisted of 20 flaps. The standard bipedicled delay pattern increased the percentage survival of the delayed inferior epigastric neurovenous flap. The survival percentage of the delayed flaps was 59.8 +/- 185.0 (P < 0.5). The histologic findings of the skin revealed that our delay procedure enhanced the perfusion of the flap by dilating the arterial network. Stimulated by our experimental findings, we used the island bipedicled surgical flap delay or combined strategic-standard delay in the distally pedicled sural flap successfully on 9 cases.

Free rectus abdominis muscle flap with plantar skingraft--a combined method of aesthetic and functional reconstruction of the heel.

A 16-year-old girl presented with a contusion of the left calcaneus that was treated by combined free rectus abdominis muscle flap and plantar skin graft. The main advantages of this procedure are that it replaces weight-bearing skin of the heel with histologically similar skin from the instep, and the fibrofatty pad of the heel with muscle; it provides a good cosmetic result in the heel, and the scars of the donor site are well-hidden.

No-touch technique for autologous fat harvesting.

A new technique for autologous fat harvesting is presented. It is termed the "no-touch" technique because the concentrated fat graft is obtained with no handling of fatty tissue. With the no-touch technique, fat aspiration is performed under tourniquet. There is no need for any mechanical manipulations such as centrifugation, washing, whisking, filtering, or straining. The medial aspect of the knee is used as the donor area. Fat is aspirated through a disposable 10-ml syringe and a 14-gauge microcannula, which consists of a curved, semiblunted tip such as that of the Tuohy needle. What remains in the syringe is the concentrated fat without blood, serum, or lidocaine. The authors report their experience with 30 patients.

Proximally pedicled musculocutaneous anterior interosseous flap for cubital fossa reconstruction.

Based on preexisting anatomic studies and our experience related to the upper extremity flaps, a proximally pedicled anterior interosseous flap was developed and used in 1 patient for the reconstruction of skin defect of cubital fossa and the biceps brachii muscle. The distal half of the brachioradialis muscle was included in the flap. The recovery of the elbow was excellent, with a full range of movement. The important conclusion from this case is that the superior perforating branch of the anterior interosseous artery may be used as the basis of an alternative regional flap for the cubital fossa.