Free ALT Perforator Flap in Nonobese Patients: The Recontouring of Soft Tissue Defects Around Foot.

BACKGROUND: The anterolateral thigh (ALT) perforator flap is well-described and versatile option for reconstruction of soft tissue defects around foot and ankle. This retrospective review was performed for reconstruction of soft tissue defects around foot with ALT perforator flaps in patients with normal and overweight body mass index (BMI). METHODS: Between January 2016 and November 2020, ALT flaps were used in 30 patients for foot defects. RESULTS: Etiologic factors were trauma (18 patients), diabetic foot ulcer (6 patients), tumor (3 patients), infection (2 patients) and burn contracture (1 patient). Mean body mass index (BMI) value was 24.9 ± 4.1 (17-30). Mean flap dimension was 145 ± 86 (40-420) cm2. Recipient vessels were anterior tibial artery in 17 patients (56%), posterior tibial artery in 12 patients (40%), reversed flow dorsalis pedis artery in 1 patient (3.3%). In 24 patients (80%), 2 vein anastomoses were done. Debulking were applied in two patients (6.6%). Donor area was grafted in four patients (13.3%). Mean flap score was 1.25 ± 0.5. Mean flap thickness was 10 ± 2 (7-14) mm. Visual Analogue Scale (VAS) score was 7.75 ± 1.04 (6-10). The patients were followed up for a mean of 14 ± 11 (1-30) months. CONCLUSION: We think that ALT flap is still reliable and precious option because it provides ideal soft tissue reconstruction by means of recontouring of foot in nonobese patients.

Anatomical Landmarks of the Beard Region.

BACKGROUND: With recent advancements in hair restoration techniques, hair can be transplanted into nonscalp areas, such as the beard region, and the result looks natural. Although scalp zones and landmarks have been available for planning and designing the hairline, landmarks that will determine the beard lines are yet to be presented and made known for clinical practice. OBJECTIVE: This study aimed to determine and analyze the beard lines and anatomical boundaries of the beard area to provide a more natural restoration/reconstruction appearance. MATERIALS AND METHODS: The soft-tissue landmarks of the face that will enable physicians to create natural-looking beard lines were determined. Based on these important points, beard lines were analyzed with anthropometric methods by using the photographs of 32 male volunteers. RESULTS: The ideal upper and lower beard lines and the anatomical boundaries of the beard area were determined using these landmarks. CONCLUSION: These lines ensure that beard restoration/reconstruction provides a more natural appearance.

Early Suspicion of Heparin-Induced Thrombocytopenia for Successful Free Flap Salvage: Reports of Two Cases.

Heparin-induced thrombocytopenia (HIT) is an underestimated complication of heparin treatment. Flap loss and related morbidity (even mortality) are caused by occlusion of the capillary vessels by a highly immunogenic complex formed by adherence of antiheparin antibodies to platelet factor 4. Early suspicion and effective treatment of HIT developing in two free flaps are described. We report on the management of two patients with HIT. Both patients were treated successfully by early suspicion and hematology consultation. Heparin products were discontinued; the patients were switched to a nonheparin anticoagulant. We emphasize the importance of early diagnosis, hematologist assessment, and a change to a nonheparin anticoagulant to prevent flap failure and possibly the catastrophic consequences of such failure.

Hybrid reconstruction of distal nasal defects.

We present hybrid reconstruction of distal lateral "through-and-through" nasal defects (skin, cartilage, and mucosa) due to resection of tumor and/or infection. Retrospective descriptive study. The study was performed in multicenter clinics between July 2011 and September 2016. 13 patients with full thickness distal nasal defects secondary to tumor and/or infection were included. Defects included dorsal and/or caudal septum, upper lateral cartilage, or inner/outer nasal valve. Caudal-based turn-in flaps were planned and used to repair inner lining of nasal cavity. Conchal and septal cartilages were used as cartilage grafts. Skin defects were reconstructed with lateral nasal artery perforator flaps. All flaps healed uneventfully, without flap loss. Nasal passage collapse, adhesion, or difficulty in breathing were not seen. No hematoma, infection, and deformity at cartilage graft donor areas was observed. During nasal reconstruction, it is mandatory to consider 3D complex and functional structure of nose. The repair of skin defects may not be enough for functional restoration. We believe that single step reconstruction of full thickness nasal defects through hybrid reconstruction may lead to anticipated successful results.

A Basic Algorithmic Surgical Approach for Nicolau Syndrome.

BACKGROUND: Nicolau syndrome (NS) is a rare complication that develops after the administration of intramuscular diclofenac sodium. The etiology and surgical treatments of 11 patients with NS were evaluated and studies in the literature were examined. The aim of this study was to compose a basic algorithm for surgical approaches to treat NS. MATERIALS AND METHODS: Eleven patients were evaluated for NS between December 2013 and January 2018. Two patients did not accept treatment, and nine patients underwent surgical debridement of necrotic tissues. The tissue defects of five patients were closed with a fasciocutaneous flap and, in four patients, the defects were repaired primarily. RESULTS: No complications, such as wound infection, wound dehiscence, seroma, or flap necrosis, were encountered. Of the seven patients who received concurrent antibiotic therapy, no patient had any problems at their follow-up (2-30 months). The results were satisfactory from an aesthetic and functional point of view. CONCLUSION: NS was more frequent in women with a high body mass index and high fat in gluteal regions. We considered that any kind of medication could lead to NS. Different methods are discussed for treatment.

Recommendations for management of diabetic foot ulcers during COVID-19 outbreak.

COVID-19 pandemia began in Wuhan, China, in December 2019. A total of 1 878 489 people were infected and 119 044 people were lost because of the disease and its complications by 15 April. Severe morbidity and mortality complications are mostly seen in elderly and patients having comorbidities. Diabetic foot ulcers (DFUs) are one of severe complications of diabetes mellitus and it may require urgent surgical interventions. In this paper, we aimed to create a management algorithm to prevent the unexpected complications that may occur in the patients and health care workers during the evaluation of COVID-19 in DFU patients who require urgent surgical intervention. We advise the use of thorax computerised tomography for preoperative screening in all DFU patients with severe signs of infection and especially those requiring urgent surgery for both the detection of the possible undiagnosed COVID-19 in the patient for the need for close follow-up and protection of the surgical and anaesthesiology team.

Counter Autografting of Dorsal Septum in Crooked Nose.

INTRODUCTION: The nasal septum plays an important role in nasal form and function. In this study, we describe a novel, alternative septoplasty approach that results in an aesthetically acceptable dorsal profile and improves airway function in patients with a crooked nose. PATIENTS AND METHODS: This study enrolled 26 patients who presented with crooked noses between 2012 and 2017. All patients underwent open rhinoplasty under general anesthesia. During correction of the cartilaginous part, a dorsal strip from the deviated septum was prepared and inverted in a 180° fashion to exert a counter-force to correct the remaining septum and fixed by suturation. This maneuver allowed application of the maximum possible force in the opposite direction to reset the deviation by its own force. RESULTS: The approach was used successfully in 26 patients with severe nasal septal deviations in the caudal septum and dorsal angulation of the nasal shape. There was no case of hematoma, synechia, septal perforation, dorsal irregularity, or saddle deformity. Temporary nasal obstruction occurred in 4 patients but improved in all of them by the third postoperative month. One patient had a recurrence of the septal deviation, dorsal angulation, and persistent nasal obstruction, which were treated by revision nasal valve surgery 14 months postoperatively. There was no subsequent recurrence during the long-term follow-up. The improvement between the preoperative and postoperative 12-month deviation angle measurements, Nasal Obstruction and Septoplasty Effectiveness (NOSE) scores were significant (P < 0.05), Improvement in the NOSE score correlated strongly and significantly with deviation angle changes and patient satisfaction. CONCLUSION: Our counter-autografting technique in septoplasty is safe and effective in the correction of severe dorsal and/or caudal deviations, as long as the severely angulated cartilage septum remains in one piece after careful dissection. 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 .

Revisiting the Limberg flap for central midface reconstruction in elderly patients.

To present the use of Limberg flap in the central midface reconstruction as an useful flap in elderly patients. A retrospective review of a total of 13 cases who underwent Limberg flap procedure to reconstruct various sizes of midfacial defects. Etiology, size, location, surgical procedures, outcomes, and complications, final evaluation according to the tumor-free survival and patient satisfaction in terms of aesthetic appearance were analyzed, the latter was evaluated by visual analog scoring system. The mean follow-up period was 11.53 months (2-22 months). The mean age of cases was 68 years (between 49 and 81 years). Average defect size was 7.76 cm2 (between 2.25 and 25 cm2 ). All operations were performed under local infiltration anesthesia. All patients were discharged on the same day of the operation. All the flaps survived with uneventful wound healing according to the patient satisfaction scores that were reliable and high. No any early or late recurrence was detected. Limberg flap is a safe and rapid option that could be applied in small- and medium-sized cutaneous defects in the central midface reconstruction in elderly patients.

Double-Layer Reconstruction of the Achilles' Tendon Using a Modified Lindholm's Technique and Vascularized Fascia Lata.

Loss of the Achilles' tendon with overlying soft tissue and skin defects remains a complex reconstructive challenge. Herein we present our experience using a free composite anterolateral thigh (ALT) flap with vascularized fascia lata and a modified Lindholm's technique to repair the Achilles' tendon. A 37-year-old man suffered from tertiary Achilles' tendon rupture. For reconstruction, the free composite ALT flap with vascularized fascia lata was used to wrap Achilles' tendon. A modified Lindholm's technique was used to cover overlying soft tissue defects. The patient was followed up for 12 months. No wound healing problems were reported, and the patient was able to walk and return to his daily ambulating activities without any support after 5 months postoperatively. This technique may be useful to achieve satisfactory outcomes in patients with ruptured Achilles' tendons following tertiary repair.

A simple concept for covering pressure sores: wound edge-based propeller perforator flap.

We present a new surgical modification to allow propeller perforator flaps to cover pressure sores at various locations. We used a propeller perforator flap concept based on the detection of newly formed perforator vessels located 1 cm from the wound margin and stimulated by the chronic inflammation process. Between January 2009 and January 2017, 33 wound edge-based propeller perforator flaps were used to cover pressure sores at various locations in 28 patients. In four cases more than one flap was used on the same patient. The patients comprised 18 males and 10 females with a mean age of 41·25 (range, 16-70) years. All patients underwent follow-up for 0-12 months. The mean follow-up duration was 5·03 months. Venous congestion was observed in three flaps that were rotated by 180° (9·1%). However, there was a significant difference between flaps rotated by 90° and 180° according to the complication rate (P = 0·034). Out of 33 flaps, 29 flaps healed uneventfully. Patients were able to sit and lie on their flaps three weeks after surgery. In our study, we were able to obtain satisfying final results using these novel flaps.

Combination of Würinger's Horizontal Septum and Inferior Pedicle Techniques to Increase Nipple-Areolar Complex Viability During Breast Reduction Surgery.

BACKGROUND: Breast reduction techniques depend on the vascularity of the pedicle. Preserving vascularity of the nipple-areolar complex (NAC) is mandatory for reduction mammoplasties, as the NAC is the most important aesthetic and functional unit of the breast. The inferior pedicle technique is the most common method for breast reduction; however, pedicle length may increase after using this technique and cause problems related to NAC viability in gigantomastic and hypertrophic breasts. In this study, we present our technical approach to preserve NAC viability by combining Würinger's horizontal septum and inferior pedicle techniques. METHODS: This study included 60 women (mean age 39.71 ± 10.52 years) who underwent a breast reduction combining Würinger's horizontal septum and inferior pedicle procedures from April 2012 to January 2016. All patients were marked preoperatively in a standing upright position using a prefabricated Wise-pattern template. The base of the pedicle was marked at the level of the inframammary ridge at a width of 8 cm. RESULTS: The patients were followed up for a mean of 5.6 ± 3.3 months. The resection weights of the right and left sides were 1406 ± 566 and 1340 ± 563 g, respectively. Venous insufficiency was encountered in five cases (8.3%) and caused partial NAC necrosis in one case (1.6%). No cases of total NAC necrosis were encountered. Fifteen breasts (12.5%) were described as gigantomastic (resection weight >2000 g). CONCLUSIONS: This combined method may promote safer and more satisfying outcomes from inferior pedicle breast reduction. 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 .