Effect of Reduction Mammoplasty on Insulin and Lipid Metabolism in the Postoperative Third month: Compensatory Hip Enlargement.

BACKGROUNDS: The positive effects of reduction mammoplasty on metabolic profile have been shown in a limited number of studies. This study objective to reveal the effects of reduction mammoplasty on metabolic profile and anthropometric measurements. SUBJECTS AND METHOD: The study was prospectively conducted on 42 patients who were operated between April 2019 and March 2020. Fasting plasma glucose, fasting plasma insulin, total cholesterol, triglyceride, high-density lipoprotein and low-density lipoprotein cholesterol, HgA1c, homeostasis model assessment scores, adiponectin, leptin, and resistin levels were evaluated. In addition, age, height, weight, body mass index; breast, chest, waist, hip circumference; waist-hip ratio, and bilateral breast resection tissue weights were recorded. Data and blood samples were collected one hour before the operation, 6 and 12 weeks after the operation. RESULT: The patients' mean age was 43.14±10.24, and their average height was 159.42±4.96 cm. The excised bilateral dermo fatty tissue weight was 1435.85±721.16 g. At the postoperative 40th day a decrease in leptin (p = 0.001), resistin (p =0.008), glucose (p = 0.021) and insulin resistance values (p=0.013) stated. There was an increase in adiponectin (p < 0.001) and HDL (p = 0.013) levels at the postoperative 40th day. In the postoperative third month, these data returned to the previous levels that were measured before operations. However, an increase in hip circumference (p = 0.034) and a decrease in waist-hip ratio (p < 0.001) was detected in third month. Also, there was no difference in body mass index and weight compared to pre-operation. CONCLUSION: After reduction mammoplasty, compensatory fat growth in the hip area, an increase in the hip circumference, and a decrease in the waist-hip ratio were observed in the postoperative third month. LEVEL OF EVIDENCE: 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 .

The effect of stromal vascular fraction in an experimental frostbite injury model.

BACKGROUND: Despite current treatment modalities, frostbite remains an injury with a poor prognosis which may cause functional morbidities. Several experimental and clinical studies have demonstrated that stromal vascular fraction is an autologous mixture, which can improve wound healing and vasculogenesis. The aim of this study was to show the beneficial effects of stromal vascular fraction on experimental frostbite healing. MATERIAL AND METHODS: Stromal vascular fraction (SVF) was harvested from 5 rats after excision of the inguinal fat pads. Another 20 rats were separated into 2 groups of 10 as the SVF group and the control group. A frostbite injury was created on each rat using a cryoprobe frozen with liquid nitrogen (-196 °C). SVF was applied to the SVF group and phosphate-buffered saline to the control group. All injections were performed subcutaneously within the frostbite injury area. Biopsies were performed on days 5 and 14 for histopathological and immunochemical evaluations. The tissue perfusion rates of both groups were assessed on day 14 using indocyanine green angiography (SPY system). RESULTS: The increase in mean tissue perfusion was 373.3% ( ± 32.1) in the SVF group and 123.8% ( ± 16.3) in the control group (p < 0.001). The macroscopic wound reduction rates of the SVF and control groups were 25.5% ( ± 19.1) and 18.0% ( ± 5.9), respectively on day 5%, and 78.2% ( ± 9.2) and 57.3% ( ± 16.7) on day 14 (p = 0.007; p = 0.003). Acute inflammation and the fibrosis gradient were significantly decreased in the SVF group compared to the control group (p = 0.004, p = 0.054 respectively on day 14). Granulation tissue amount, re-epithelialization score and neovascularization were significantly increased in the SVF group (p = 0.006, p = 0.010 and p = 0.021, respectively on day 14). CONCLUSIONS: The study results demonstrated that SVF increases frostbite wound healing by increasing tissue perfusion rate, neovascularization and re-epithelialization, and modulating acute inflammation and fibrosis.

A Novel Basic Training Laboratory Model on Live Subjects for Supermicrosurgery: Mouse Femoral Artery, Vein and Nerve.

BACKGROUND: Increasing success rates of supermicrosurgery operations have increased the importance of developing the ideal training model for super-microsurgery. Working on the model is very important for increasing and continuing microsurgery and supermicrosurgery skills. We aimed to present a standardized, simple and easy to access live training model for supermicrosurgery. METHODS: The experiment was performed in the University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, IDEA, Istanbul, Turkey in 2020. Twelve BALB/c male albino mice weighing 20-45 gr were used in the study. Unilateral femoral artery, vein and nerve diameters of mice were measured. Anastomosis was performed on the bilateral femoral vessels. The surgical procedure times were also recorded. RESULTS: The mean weight of the mice was 36.6 ± 6.09 gr, the length was 15.10 ± 1.10 cm. The mean external diameter of the femoral artery, vein and nerves were 0.31 ± 0.34 mm, 0.48 ± 0.70 mm, 0.38 ± 0.43 mm, respectively. The mean preparation time of neurovascular structures for anastomosis was 15.75 ± 1.54 min, mean femoral artery and vein anastomosis time was 24.91±1.72 and 33.16±1.74 min, respectively. Vascular patency was detected as 100% after all vascular anastomosis procedures. CONCLUSION: Mice femoral neurovascular structures are similar to rats in terms of basic morphology, and they are small enough for super-microsurgery education model. Dissection of mice femoral bundles are easy to perform. In terms of training models, anesthetic requirement and laboratory costs are less for mice, and handling them is much easier compared to rats; thus, making them especially suitable for basic supermicrosurgery training courses.

The Effects of Vasonatrin Peptide on Fat Graft Viability: An Experimental Study.

Vasonatrin peptide (VNP) is a synthetic peptide that possesses vasodilatory, natriuretic, and anti-inflammatory properties. The authors aimed to analyze the effects of VNP on fat graft survival. Twenty Sprague-Dawley rats are randomly divided into two groups of 10. Fat grafts are harvested from the right inguinal region. After preparation, fat grafts are placed to the interscapular region. The first group of rats were administered VNP after their fat injection, while the second group received tail-vein injections of an equal volume of sterile saline following their fat injection. Experiment and control groups are evaluated according to their level of degeneration of adipocytes, fat necrosis, vacuolization, cyst formation in adipocytes, fibrosis of the fat tissue, capillary density, and CD31 immunohistochemical staining. Degeneration, vacuolization, and cyst formation in adipocytes were lower in the experiment group. Increased capillary density in the experiment group was demonstrated by CD31 antibody staining and by counting capillary density under a microscope. The average percentage of change in weight of the fat grafts in the experiment group was lower than that in the control group. The results indicate that VNP has some beneficial effects on fat graft survival by multiple independent mechanisms that influence both local and systemic homeostasis.

The Effect of Very Low Concentrations of Ethanol on Microvascular Artery and Vein Anastomosis: An Experimental Study.

OBJECTIVES: This study investigated the effect of very low concentrations of ethanol on artery and vein anastomosis. Also, it was aimed to determine the appropriate ethanol concentration to be used in vasospasm. METHODS: Rats were divided into five groups of eight rats, each group, as follows: Group i: saline; Group ii: 2.5% ethanol; Group iii: 5% ethanol; Group IV: 7.5% ethanol; and Group V: 10% ethanol. During the femoral artery and vein anastomosis, 1ml of the agent was used for irrigation in each group. Vessel diameters were measured before the anastomosis, at the fifth and 15th minutes, and the third week after the anastomosis. Histopathological samples were taken in the third week. RESULTS: In Groups ii and iii, the mean vessel diameters were found to increase 15th minute. Also observed was an increase in mean vessel diameter that continued in the third week. Although acute vasodilation was detected in Groups IV and V, arterial and venous thrombosis was observed in the third week. Intima and media thickness decreased in Group ii, while it increased in Group iii. Perivascular inflammation and fibrosis increased as the ethanol concentration increased. CONCLUSION: 2.5% ethanol causes acute and prolonged vasodilation and does not cause endothelial cell damage, perivascular inflammation, and fibrosis. 2.5% ethanol will be a powerful alternative use in many situations that occur with vasospasm.

Perivascular Injections of Botulinum Toxin Type A Versus Low Concentration of Ethanol.

BACKGROUND: This study aimed to investigate the effect of low concentration ethanol in increasing flap viability by perioperative perivascular application and compared it with that of botulinum toxin type A (BTX-A). MATERIALS AND METHODS: Twenty-seven Wistar albino rats weighing 300-350 g were used in this study. The subjects were randomly divided into three equal groups: group E (ethanol, n = 9), group B (BTX-A, n = 9), and group S (saline, n = 9). In rats, the dorsal multi-territory perforator flap was elevated, and the agents were injected. In postoperative 1 wk, flap viability and vascular endothelial growth factor levels were evaluated. Also, blood flow, microvascular density, and inflammation degree of both choke zones were assessed. RESULTS: The mean flap survival area and vascular endothelial growth factor level were significantly higher in group E than in group B and S (P < 0.001). Similarly, blood flow (first choke zone, P < 0.012, and second choke zone, P < 0.001) and microvascular density (first choke zone and second choke zone, P < 0.001) were found to be higher in Group E compared to Group B and S in the evaluation performed from both choke zones. Also, significant inflammation was detected in the ethanol group. CONCLUSIONS: The positive effects of BTX-A on flap viability were achieved with a low concentration of ethanol. The fact that a low concentration of ethanol increases blood flow, angiogenesis, and flap viability more than BTX-A in the first postoperative week indicates that it can be an alternative agent for perioperative use.

Reconstruction of Complex Scalp Defects in Different Locations: Suggestions for Puzzle.

OBJECTIVE: Scalp defects may occur following trauma, radiotherapy, oncologic resection, and recurrent surgeries. The hair-bearing scalp has a dual role, which consists of protecting the calvarium and contributing to aesthetic appearance. While the "reconstructive ladder" approach may be used to close small and medium-sized scalp defects, it is not the case for larger ones involving the calvarium or with a radiation therapy history. The aim of this study is to present cases operated due to complex scalp defects, analyze complications, and discuss the choice of reconstruction. MATERIAL AND METHODS: The study consists of 14 patients who were operated between December 2017 and August 2019 due to a complex scalp defect. Patient were evaluated according to age, gender, etiology, radiation therapy history, defect size and location, reconstruction steps, cranioplasty and duraplasty options, type of free flap, recipient artery, vein graft requirement, and complications. RESULTS: The mean age of patients, which consists of 11 men and three women, was 56.7 years. The etiology for scalp defects included basosquamous carcinoma, squamous cell carcinoma, giant basal cell carcinoma, atypical meningioma, glioblastoma multiforme, angiosarcoma, and anaplastic oligodendroglioma. The defect involved the full thickness of calvarium in nine cases and pericranium in five cases. Cranioplasties were made with rib graft (n=1), bone graft (n=1), and titanium mesh (n=7). Free flaps used for reconstruction were musculocutaneous latissimus dorsi (LD) (n=4), LD muscle (n=3), anterolateral thigh (ALT) (n=4), musculocutaneous ALT (n=1), vastus lateralis muscle (1), and rectus abdominis muscle (n=1). Flap loss was not observed. Complications occurred in four of the patients; include a partial graft loss, a wound dehiscence, seroma, and an unsatisfactory esthetic result. CONCLUSION: Free tissue transfers rather than local flaps should be opted to reconstruct complex scalp defects, as failure of the latter, could create much greater defects, and worse consequences. There are many options for proper reconstruction, and it is essential to select the appropriate one, taking into account the comorbid conditions of each case.

Discussion of Histopathological Findings of 954 Breast Reduction Specimens.

OBJECTIVES: Breast reduction is a frequently sought procedure by patients and one of the most commonly performed operations by plastic surgeons. Follow-up of histopathological results after reduction mammoplasty is very important. This study aimed to evaluate the histopathological results of patients undergoing bilateral reduction mammoplasty to determine the incidence of breast lesions and risk factors of high-risk breast lesions. METHODS: 477 patients who underwent reduction mammoplasty in the plastic surgery department between October 2013 and January 2020 were included in this study. Patients were evaluated according to age, body mass index (BMI), comorbidity factors, tobacco use, family history and histopathological findings. RESULTS: The mean age of patients was 42.43±12.05 years. Body mass index ranged from 23 to 34.6. As for comorbidity factors, 12 patients had hypertension, five patients had asthma and six patients had diabetes mellitus. Seventeen patients (3.6%) were smokers, and 25 (5.2%) patients had a family history of breast cancer. Among the patients, 2.3% were 20 years and under, 17.1% were between 21 and 30 years old, 21.5% were between 31 and 40 years old, 33.1% were between 41 and 50 years old, 18.2% were between 51 and 60 years old, and 7.5% were 60 years and above. 85.4% of histopathological findings consisted of normal breast tissue and nonproliferative breast lesion breast lesions. The incidences of proliferative breast lesions, atypical hyperplasia and in situ lesions were calculated as 5.7%, 2% and 0.4%, respectively. The mean follow-up period was 3.8±1.6 years. CONCLUSION: Although preoperative breast cancer screening methods are used before the reduction mammoplasty, high-risk lesions may be encountered afterwards. One of the biggest advantages of reduction mammoplasty in addition to psychophysiological recovery is breast cancer risk reduction.

Effect of Tacrolimus on Peripheral Nerve Regeneration in Allograft Transplantation: A Light and Electron Microscopic Study.

OBJECTIVES: Peripheral nerve injuries are common in Europe; however, the treatment techniques may lead to disabilities. This study aimed to evaluate the effect of tacrolimus use on the capacity of the epineural sheath graft to improve its regeneration quality in rat sciatic nerves as a treatment option for nerve injuries. MATERIALS AND METHODS: In the experimental process, 30 male Sprague Dawley were used as recipients and 10 Wistar rats were used as donors. Under anesthesia, all rats were operated on to resect the sciatic nerve. The nerve tissue of Wistar rats was used as allograft. In the autograft group, the resected nerve was reversed and sutured, resulting in an epineural sheath graft. For the allograft groups, rats were randomly divided into 2 groups as the tacrolimus-treated group and the nontreated group after allograft transplant. Tacrolimus was administered intramuscularly at 0.1 mg/kg daily for 12 weeks. After the treatment period, rats were killed and evaluated histomorphologically with light and electron microscopy. RESULTS: Histological examination showed no remarkable differences between different regions of the sciatic nerves (distal, middle, and proximal). The axonal density was decreased in the allograft groups compared with the autograft group (P < .001). Results showed that the number of mast cells was increased in the allograft group without tacrolimus treatment (P < .05). Similarly, there was a mild increase in mast cell count in the tacrolimus-treated allograft group. CONCLUSIONS: Our results showed that tacrolimus use in rats with implanted epineural nerve sheath supported recovery in terms of morphological and physiological regeneration of the nerve.

Neutrophil Elastase Inhibitor Increases Flap Survival in Experimental Degloving Injuries.

OBJECTIVES: Degloving hand injuries have generally been viewed as among the most difficult of injuries to manage due to the extensive nature of associated damage. The traditional approach to the circumferentially degloved segment of problematic flap viability has been to resuture the flap and to wait and see. However, the waiting period or the specific hemorheological protocol remains uncertain. This study aims to acknowledge if Sivelestat, known to ameliorate ischemia-reperfusion injury, enhances the survival of avulsed flaps in a hind limb degloving model of rats and to compare Sivelestat's effects to Pentoxifylline. METHODS: In this study, total flap area (cm2), area of necrosis in the flap (cm2), and the ratio between the necrotic and total areas (percentage) were determined. Angiogenesis among the groups was documented with CD31, anti-PECAM staining. TUNEL assay was performed to allow the visualization of cell nuclei containing fragmented DNA, a typical feature of apoptosis. RESULTS: The findings obtained in this study showed that Sivelestat administered at 10 mg/kg/hour dosage will inhibit the ischemia-reperfusion injury more pertinently than Pentoxifylline, which exerts only hemorheological effects. CONCLUSION: The anti-inflammatory effects of Sivelestat will be beneficial for decreasing the early complications of degloving injury, such as inflammation, sepsis, and edema, better than Pentoxifylline, which exerts only hemorheological effects.

The Keystone, Scroll Complex, and Interdomal Area of the Nose: Histologic and Anatomical Observations.

Comprehensive knowledge of nasal anatomy is essential for obtaining aesthetically and functionally pleasing results in rhinoplasty. In this study, the authors described the anatomy, histology, and clinical relevance of the interdomal region, keystone, and scroll complex. The current study examined these areas in 26 fresh cadaver heads. All cadavers were fresh, and no conservation or freezing processes were applied. All dissections were performed by the first author. It was determined that the structure that connected the middle crura in the interdomal region actually came together in the transverse plane and contained abundant capillaries within. It was observed that chondroblasts with high regenerative potential were present in the keystone area, and there was very tight attachment between periosteum and perichondrium. The scroll complex was found to be more flexible and thin and had fewer regenerative cells compared to the keystone region. With its unique anatomy and histology, the keystone acts as a transition area between the flexible and fixed units of the nose. The scroll complex should be taken into consideration during rhinoplasty because of its effects on fixation of the skin in the lateral supratip area and functional effects on internal and external nasal valves. The interdomal ligament, in contrast, acts as a transition between both middle crura rather than a real ligament.

The effects of human amniotic membrane on silicone related capsule formation in rats.

Silicone breast implants are commonly used materials in plastic surgery for breast augmentation and reconstruction and the most severe complication of silicone implants are capsule contraction which occurs in 40% of patients. The aim of our study is to evaluate how the amniotic membrane alters the capsule formation effects of silicone 24 wistar rats were used in the study. We placed a bare silicone block into the left side (Subgroup A) and single layer amniotic membrane coated silicone block into the right side (Subgroup B) of the rats back. The rats were then separated into three groups and in group 1 rats were euthanized after 3 weeks, in group 2 after 12 weeks and in group 3 after 24 weeks. Then capsule thickness, fibroblast and lymphocyte cell counts were evaluated for each sample. In Group 2 and group 3, the capsule thickness in Subgroup B was detected to be statistically significantly lower than that in Subgroup A. In Group 1, 2, and 3, the lymphocyte count in the capsule tissue taken from Subgroup B was lower than Subgroup A but the difference was not statistically significant. In Group 2 and 3, the fibrocyte count detected in the capsule tissue in Subgroup B was found to be statistically significantly lower than Subgroup A. the amniotic membrane was demonstrated to reduce capsule thickness by the antifibrinolytic effect in our study.

Does Wide Excisional Biopsy in Skin Cancer Prevent Finding The Real Sentinel Lymph Node?

Purpose/Aim: The presence of nodal metastasis is an important prognostic factor for malignant melanoma and causes a 50% decrease in survival. Patients found not to have lymph node metastasis as a result of sentinel lymph node biopsy but develop regional lymph node metastasis in the follow-up period are called false negative sentinel. The hypothesis of this study was that excisional biopsy in patients with large lesions may change the lymphatic pathway and therefore cause false negative results. Materials & Methods: A total of 40 Sprague-Dawley rats were divided into 4 groups: the control group, Group 1 (10 mm excision), Group 2 (15 mm lesion excision), and Group 3 (20 mm excision). Sentinel lymph nodes were found via imaging with nanocolloidal albumin including 99mTc and indocyanine green (ICG) before the excision and at 3 weeks after the excision. Evaluations were performed to determine whether or not they were the same nodes. Results: The false sentinel node detection rate in Group 3 was significantly higher than in both the control group and Group 1 (p < 0.05). No significant difference was detected between Group 2 and 3 according to false sentinel node detection rate. There were differences between preoperative and postoperative detection of sentinel lymph nodes found by radioactive and ICG methods but no significant difference was detected in the Kappa agreement coefficient. Conclusion: It can be suggested that incisional biopsy is performed on large lesions initially, followed by wide excision combined with SLNB at the second stage. This can help to prevent changes in the lymphatic pathway and therefore to decrease false negativity rates caused by the previous surgery.

Posterior Arm Perforator Flap for Axillary Reconstruction After Hidradenitis Suppurativa Excision.

INTRODUCTION: Hidradenitis suppurativa (HS) is a chronic inflammatory disease arising from the hair follicles in apocrine gland-rich areas. It is also one of the most common indications for axillary surgery. Reconstruction of the axillary region after such surgery must be performed meticulously due to its critical location and crucial content. In this report, we present our experience of reconstruction of axillary defects with posterior arm perforator flaps (PAPF) following radical excisions. METHODS: A total of 14 patients (9 male, 5 female) aged between 16 and 49 years who had presented with HS in the axillary region and, after surgery, underwent reconstruction with either island or skin bridge posterior arm flap between January 2015 and October 2016 were included in the study and evaluated retrospectively. All of the defects were reconstructed with PAPF following wide excision. RESULTS: Five of the flaps (over 4 patients) were designed as flaps with skin bridges, while the remaining 12 flaps in 11 patients were raised as island flaps. The flaps had areas ranging from 20 to 84 cm2 (mean 39.5 cm2), depending on the size of the defect after excision. The mean follow-up time after the operation was 6 months. Wound dehiscence was detected in one patient, and another patient developed marginal necrosis during the postoperative period; no other complications were observed. CONCLUSION: Posterior arm perforator flaps can provide sufficient amounts of soft tissue to cover axillary defects and should be considered as the flap of choice in axillary reconstruction.

INTRODUCTION: La maladie de Verneuil (MV), ou hidrosadénite suppurée, est une maladie inflammatoire chronique qui touche les follicules pileux situés près des glandes apocrines. C'est également l'une des indications les plus courantes de chirurgie axillaire. Il faut procéder à une reconstruction méticuleuse de la région axillaire après l'opération en raison de son emplacement difficile et de son contenu crucial. Dans le présent rapport, les auteurs présentent leur expérience de reconstruction des anomalies axillaires à l'aide de lambeaux perforants du bras postérieur (LPBP) après des excisions radicales. MÉTHODOLOGIE: Au total, 14 patients (neuf hommes, cinq femmes) de 16 à 49 ans atteints d'une MV dans la région axillaire qui ont subi une reconstruction par lambeau en îlots ou par pont cutané prélevé sur le bras postérieur entre janvier 2015 et octobre 2016 ont participé à l'étude et fait l'objet d'une évaluation rétrospective. Les chirurgiens ont reconstruit toutes les anomalies à l'aide de LPBP après une large excision. RÉSULTATS: Cinq des lambeaux (sur quatre patients) étaient sous forme de ponts cutanés, et les 12 autres (sur 11 patients) ont été prélevés en îlots. Les lambeaux étaient d'une taille de 20 à 84 cm2 (moyenne de 39,5 cm2), en fonction de la dimension de l'anomalie après l'excision. Le suivi moyen était d'une durée de six mois après l'opération. Un patient a présenté une déhiscence de la plaie et un autre, une nécrose marginale pendant la période postopératoire. Aucune autre complication n'a été observée. CONCLUSION: Le LPBP peut fournir une quantité suffisante de tissus mous pour couvrir les anomalies axillaires. Il faut le considérer comme le lambeau de première intention lors d'une reconstruction axillaire.

Tip Reinforcement Flap: An Original Technique for Improving Nasal Tip Support and Definition.

BACKGROUND: Middle crura support deficiency and short middle crura can usually cause insufficient definition and projection of the tip and can sometimes result in a flat tip. The aim of this study was to investigate the effectiveness of a new technique involving a tip reinforcement flap to strengthen the middle crura and to achieve a well-projected and defined tip. METHODS: Twenty-nine patients who underwent primary open-approach rhinoplasty that included the use of tip reinforcement flaps were included in the study. Cartilage flaps that had been created from the excess cephalic portion of the lateral crura were prepared as medial crura-based cartilaginous flaps. RESULTS: There were 29 patients (17 women, 12 men) aged 18 to 44 years (mean age, 31 years). Follow-up time ranged between 3 and 25 months (mean, 21 months). Preoperative and postoperative average of nasal tip length was 10.84 (±1.07) mm and 14.32 (±2.34) mm, respectively (P = 0.0214). Preoperative and postoperative average of nasolabial angle was 97.42° (±9.84°) and 107.99° (±12.16°), respectively (P = 0.0344). Preoperative and postoperative average of nasal projection ratio was 0.53 (±0.04) and 0.57 (±0.03), respectively (P = 0.4347). The tip reinforcement flap technique provided strengthening and extra support for the middle crura and increased definition, projection, and stability to the domal area. CONCLUSIONS: The tip reinforcement flap technique offers advantages for tip plasty in those cases with middle crural deficiency, short middle crura, and middle crural weakness. The technique also provides an additional projection, stabilization, and definition to the nasal tip while reducing lateral crural cephalic excess. This technique improves nostril-lobular disproportion and has the advantage of hiding extra support grafted into the folded flap. Complications such as graft visibility, malposition, and asymmetry, which may occur with the use of classic tip grafts, can be eliminated with the tip reinforcement flap technique.

Congenital lateral cleft palate with unilateral craniofacial microsomia and lateral ankyloglossia.

Craniofacial microsomia is a group of anomalies that occur due to developmental defects in the first and second branchial arches during the embryological period. The disease has various craniofacial and extracraniofacial presentation patterns. Lateral cleft palate is distinct from the most common palate clefts because it is located lateral to the uvula. The presence of a lateral cleft palate has been very rarely reported in the literature, and the aetiopathogenesis of the disease is still not well understood. We aimed to report a case of the coexistence of lateral cleft palate and craniofacial microsomia and discuss the aetiopathogenesis of these diseases.

Predicting Morbidity and Mortality in Patients with Lower Extremity Necrotizing Fasciitis.

OBJECTIVES: Necrotizing fasciitis (NF) is a rare but limb- and life-threatening soft-tissue infection. It is among the most challenging surgical infections faced by surgeons, and is often accompanied by severe systemic toxicity. The aim of this study was to evaluate the predictive power of serum lactate and creatinine levels for mortality and morbidity in lower extremity NF. METHODS: A retrospective cohort analysis of 87 patients with lower extremity NF was performed to evaluate the management techniques and the amputation and survival rates according to serum lactate and creatinine levels as well as the time between the onset of symptoms and surgery. RESULTS: The mean time between the onset of symptoms and surgery was 3.7 days. As the time between the onset of symptoms and surgery increased, the rate of amputation and mortality significantly increased (p<0.001). In all, 66% of the mortality in the group was seen among the 12 patients who had a serum creatinine level greater than 2 mg/dL at the time of presentation. In 12 of 14 patients (85.7%) who underwent amputation/disarticulation, the mean serum lactate level was 5.7 mmol/L (range: 5.1-8.7 mmol/L), and the mean serum creatinine level was 1.92 mg/dL (range: 1.4 to.3.3 mg/dL). The high levels of serum creatinine and lactate were found to be statistically significant in terms of predicting mortality and amputation (p<0.001). CONCLUSION: Based on the results of this study, it was determined that risk factors for mortality include age, late presentation, increased serum creatinine and lactate levels, and that these factors can predict the rate of death from NF at the time of presentation.

Management and Treatment of Pressure Ulcers: Clinical Experience.

OBJECTIVES: Pressure ulcers are a common healthcare problem, particularly among hospitalized patients who need long-term treatment; however, preventive medicine can reduce the prevalence. A multidisciplinary approach is fundamental to providing proper care, and the general health status and cooperation of the patient determine treatment modalities. Simple methods can prevent pressure ulcers and their recurrence. The aim of this study was to share clinical experience and evaluate the approach and treatment modalities used for pressure ulcers. METHODS: Fifty-two patients hospitalized with the indication of pressure ulcers were evaluated retrospectively. Age, sex, localization of the decubitus ulcer, treatment method, comorbid diseases, and any postoperative complications were analyzed. RESULTS: Thirty-five patients were male and 17 were female. The mean age was 50.3 years. The most common accompanying disease was diabetes mellitus and the most common etiology was paraplegia. Pressure ulcers were localized on the sacral area in 45 patients, the ischial area in 23, the trochanteric area in 11 patients, and other parts of the body (scapular, lumbar) in 3 patients. Fasciocutaneous rotation flaps, myocutaneous flaps, and perforator flaps were the most used reconstruction techniques. No major complication was observed. CONCLUSION: The most important point with regard to pressure ulcers is prevention. Healthcare system expenses can be significantly reduced by preventing the formation of decubitus ulcers. The progression of pressure ulcers can be easily controlled if the necessary care and treatment are provided in the early period. The role of the plastic surgeon in advanced stages is to perform reconstruction in appropriate cases and to educate patients and their caregivers with the aim of preventing recurrence.

Coexistance of Gynecomastia and Poland Syndrome: Case Report.

Coexistence of the Poland syndrome and gynecomastia is a rare condition. Poland syndrome requires soft tissue augmentation of the affected side, whereas gynecomastia necessitates reduction of the breast tissue. To provide symmetry, breast reduction and fat grafting techniques should be combined. We report a 29-year-old male patient with left gynecomastia and right sided Poland syndrome. In order to correct his asymmetry on the anterior chest wall, left breast tissue resection and fat grafting to the right breast were performed. Having these two opposite conditions at the same time and on the same patient makes the deformities look more dramatic than they are separately. Accurate planning and selection of proper techniques enable to provide symmetry in such cases.

Use of Roof-Shaped Costochondral Cartilage for Correction of Saddle Nose Deformity.

BACKGROUND: Cartilage grafts are routinely used in secondary and posttraumatic rhinoplasty. However, in most cases, there are weak areas in the nasal bones and upper lateral cartilages. The purpose of this study was to seek a solution for the keystone area and dorsum of the nose in revision and posttraumatic rhinoplasty cases, and reconstruction of saddle nose deformity including upper lateral cartilage with a roof-shaped graft. METHODS: A retrospective review of reconstructive rhinoplasties performed for saddle nose deformities was conducted. A part of the costochondral graft was carved and thinned (roof graft) for reconstruction of the keystone area and upper lateral cartilages, and another portion was used for making a neoseptal (reconstructed septum) graft and strut graft. The roof graft was capped onto the neoseptal graft with sutures, and this cartilage framework was adapted with fitting the cranial edge of the neoseptal cartilage between the nasal bones. Finally, the strut graft was fixed to the cartilage framework. RESULTS: A significant improvement in nasal shape and overall appearance was achieved in all cases, and 71.42 percent of patients recovered from nasal obstruction. No gross absorption, graft exposure, or recurrence of deformities was observed. CONCLUSIONS: Surgical correction of a saddle-shaped nose should be an acceptable and uncomplicated technique, and the cosmetic result should be totally acceptable. There are many management options for a saddle-shaped nose. Use of roof grafts (shrunk gull-wing grafts) with neoseptal and strut grafts enables simulation of the internal nasal valve and results in a natural nasal position. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.