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.

Evaluation of forearm arterial repairs: Functional outcomes related to arterial repair.

BACKGROUND: There are few studies of single forearm arterial injury repair that compare long-term results of intact and obliterated forearm arterial repair. Aim of the present study was to compare long-term results of forearm arterial repair using Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score and color Doppler ultrasound (CDUS). METHODS: Records of 166 consecutive patients with forearm arterial injury were reviewed, and 30 patients with same injury (ulnar artery, ulnar nerve, and tendon injuries at flexor zone V) were called back for CDUS and QuickDASH scoring. Patients evaluated with CDUS were divided into 2 groups according to results: patent vessels (Group 1) and obliterated vessels (Group 2), and statistical analysis was performed to compare QuickDASH scores of groups. RESULTS: Difference in QuickDASH scores was statistically significant: Group 1 had lower score (24.27) than Group 2 (36.34), indicating better outcome in patients with patent vessels. CONCLUSION: Vascular repair that achieved vessel patency led to better functional outcome with lower QuickDASH score and less cold intolerance.

Reconstruction of Extensive Orbital Exenteration Defects Using an Anterolateral Thigh/Vastus Lateralis Chimeric Flap.

Neglected malignant tumors within the orbital region can invade the eyeball, extraocular muscles, and bone substance surrounding the eye. Such patients require orbital exenteration, which may involve extraocular skeletal structures (even exposing paranasal sinuses), resulting in 3-dimensional defects requiring reconstruction. This study presents our experience with anterolateral thigh vastus lateralis (ALT/VL) chimeric free flaps for the reconstruction of extensive orbital exenteration defects involving various paranasal sinuses.Between 2012 and 2016, 4 patients with extensive 3-dimensional orbital defects with sinus involvement were treated using the ALT/VL chimeric flap. The ALT component (117-170 cm) was used to resurface the cutaneous defect while the VL component (105-243 cm) was used to obliterate the cavitary defect. The flaps were all based on the common descending pedicle, and branches to separate components were individually dissected. Recipient vessels were in the neck region, to which the donor pedicles were passed through a tunnel for anastomosis.All cavitary and surface defects were simultaneously reconstructed via the ALT/VL chimeric flap. Within an average of 17 months, no complications associated with flap surgery were observed. One patient received postoperative adjuvant radiotherapy with no complications. With its separate components supplied by a common vascular pedicle, the ALT/VL chimeric free flap allows the surgeon to conveniently reconstruct separate spatial and volumetric defects resulting from extensive orbital exenteration.

Accordion-style pedicle suspension in inferocentral pedicled mammoplasty.

OBJECTIVE: In breast reduction surgery, while the primary objective may appear to be decreasing the breast volume, the ultimate goal is to achieve symmetrical, appealing, and sustainable breast cosmesis. To circumvent late-term ptosis following inferior pedicle mammoplasty, methods such as pedicle suspension to the ribs, support with dermal flaps and grafts, and the use of some alloplastic materials have been proposed. This paper presents a method of folding and fixing the inferocentral pedicle on itself and the underlying pectoral fascia. METHODS: Inferocentral pedicled, inverted T-scar reduction mammoplasties were performed on 50 patients from June 2009 to June 2014. The inferocentral pedicle, which was kept narrow and long, instead of the conventional inferior-based pyramidal design, was folded over its de-epithelialised surfaces in an accordion fashion and sutured. The confection was then sutured to the pectoral fascia by its lateral and superior borders for long-term preservation of breast moulding. RESULTS: In inferocentral breast reduction, the quest for a method that achieves appealing and lasting pyramidal breast shape continues. CONCLUSIONS: This technique is regarded as a simple and effective method for achieving good short- and long-term results for patients being considered for moderate and advanced breast reduction.

Our Treatment Approaches in Severe Maxillofacial Injuries Occurring After Failed Suicide Attempts Using Long-Barreled Guns.

Maxillofacial traumas with long-barreled guns may sometimes cause catastrophic results by means of smashing in facial structures. In these patients, reconstruction strategies of both fragmented/lost soft and hard tissues still remain controversial. In their clinic, the authors treated 5 patients with severely injured face after failed suicide attempt between 2008 and 2013. In this study, the authors aimed to present their clinical experiences on these severely injured maxillofacial gunshot traumas and offer a treatment algorithm to gain a result as possible as satisfactory in terms of functionality and appearance.

Multiple Subungual Pyogenic Granulomas Following Levothyroxine Treatment.

Pyogenic granulomas are benign vascular lesions that can result from a large number of etiological factors. Drugs are one etiological factor involved in pyogenic granuloma development. In this study we present our experience of multiple pyogenic granulomas following levothyroxine administration suggesting that levothyroxine hormone replacement therapy might play an important role in the formation of pyogenic granuloma. We also reviewed the literatures regarding drug-induced pyogenic granulomas.

Rarely seen complication of motor vehicle accidents: Bilateral globe avulsion.

Avulsion of the globe is a rare condition that can occur with severe maxillofacial trauma. A few bilateral cases have been reported. The objective of this study was to present a case of this challenging condition in a 15-year-old male patient who was admitted to the emergency service after a motor vehicle accident.

Comparison between flexible collagen and vein conduits used for size-discrepant nerve repair: an experimental study in rats.

Primary nerve repair is the gold standard in nerve reconstruction. When primary repair is not possible for injured nerves, conduit-assisted repair methods are frequently used. As conduits, autologous vein segments or allogenic biodegradable products can be used. However, their effectiveness when used in a nerve defect where a size discrepancy exists has not been compared. In this study, either a vein graft or a synthetic collagen conduit was used to bridge 10-mm defects between size-discrepant tibial and peroneal nerves in a rat model. After 90 days, nerve regeneration was evaluated using electrophysiological and histological methods. It can be concluded based on the results of this study that bridging a 10-mm nerve gap with synthetic collagen conduits and autologous vein grafts yielded similar results in small-to-large nerve coaptations, with the vein graft being slightly more effective.

Penetrating maxillary sinus injury caused by a construction nail passing through the orbital cavity.

Because of its anatomic position, the orbit is frequently subject to trauma, leading to functional and cosmetic problems. After blunt trauma, orbital fractures can cause functional problems by trapping the periocular tissues without affecting the anatomic integrity of the globe. In comparison, high-energy penetrating injuries can cause serious consequences such as disrupting the lacrimal drainage system and causing loss of vision. In rare cases, however, penetration of the orbit by a foreign body can result in a treatable injury that causes no functional or cosmetic problems.This article presents a patient in whom a nail penetrated the orbit from the inferomedial margin and reached the maxillary sinus without damaging the globe, extraocular muscles, or lacrimal duct system. Reports of similar injuries are reviewed, focusing on the anatomic structures that might be traumatized, to guide the readers in considering the diagnosis and treatment of such injuries.

Comparison of oversized artery and vein grafts for interpositional pedicle lengthening in rat femoral artery.

Vessel grafting is commonly used for revascularization or pedicle lengthening. Although veins are more commonly used, they can form aneurysms when bridging an arterial gap. This can lead to thrombosis, and the risk is increased when there is a size discrepancy. This study reports the long-term results of arterial lengthening via size discrepant carotid artery and femoral vein grafts in a rat femoral artery model (1:1.5 ratio). A total of 28 rats were used in this study, divided into two groups of 14. By the 21st day, one anastomosis in each group has been found to be thrombosed. Long-term patency rates were the same for both groups (93.3%). Radiologic imaging showed that size match in the carotid artery grafts was excellent despite of slightly fusiform dilatation, but in the vein groups, pronounced aneurismal deformation and distortion in the anastomosis was seen. Histologic analysis revealed that in the arterial grafts, endothelial continuity was smooth and mural inflammation was less than that of the vein grafts. Organized or recanalized mural thrombi were seen in 38.5% in the vein grafts, whereas in arterial grafts there were none.

The synergy between endoscopic assistance and extraoral approach in subcondylar fracture repair: a report of 13 cases.

BACKGROUND: We aimed to present the primary experience of one surgeon with a new surgical technique performed on the first 13 cases and to evaluate outcomes following an extraoral endoscopic approach to subcondylar fractures. METHODS: Fifteen subcondylar fractures in 13 patients, who were treated at Ondokuz Mayis University Hospital between January 2010 and June 2011, were included in this study. Patients were operated on using either endoscopic or open approach. RESULTS: Rigid plate fixation was completed endoscopically using extraoral approach in nine fractures, while six fractures were plated by conversion to a full-open approach. In all six fractures that could not be fixed endoscopically, the proximal fragments were medially displaced, whereas seven of nine fractures that were successfully fixed endoscopically were laterally displaced. CONCLUSION: An extraoral endoscopic approach for subcondylar fractures is feasible and can be carried out with decreased morbidity. This approach is recommended for those with limited experience in endoscopy to treat low laterally displaced subcondylar fractures as their initial cases.

Simultaneous cheek and lower eyelid reconstruction with combinations of local flaps.

Cheek defects are common facial defects, especially after tumor ablation. Although primary repair yields the best aesthetic outcome, wide defects require flap resurfacing. Among the flap techniques, the cervicofacial rotation/advancement flap is one of the most common. In cases with eyelid involvement, it is very unlikely that a local flap would single-handedly resurface the defect and additional flaps must be used.This article presents our clinical experience with 14 patients with cheek defects for whom cervicofacial rotation/advancement flaps were used. In 3 of the 14 patients, local flaps that include the laterally based Tripier flap, the Fricke flap, the nasojugal flap, and the median forehead flap were combined with the cervicofacial flap to reconstruct the lower eyelid defects in accordance with the principle of individually reconstructing different anatomic subunits. All infraorbital defects were resurfaced with residual cheek and cervical skin with a good color and texture match. In patients whose eyelids were intact, no malposition was observed.Posteriorly based cervicofacial rotation/advancement flaps offer a very reliable and convenient method for resurfacing infraorbital and medial cheek defects. When a lower eyelid defect is also present, its individual reconstruction as a separate facial subunit needs to be considered using a combination of smaller local flaps.

Versatility of the pinwheel flap to reconstruct circular defects in the temporal and scalp region.

The pinwheel flap technique involves raising four small rotation flaps, which are 90° apart from each other and converge into a defect in their centre. It is suitable for resurfacing defects of the scalp, which offers limited skin mobility. It may also be used for certain circular skin defects on the hairless temporal region. This study first re-formularised the original description of this flap technique via a laboratory study. Thanks to a new smaller flap design, closure was achieved with a lesser scar. Afterwards, the technique was used on the 14 patients who had circular skin defects of the temple and scalp. Defect diameters and resultant scar lengths were recorded. When the new design was used, scarring required for defect closure was less than half of that required for the original design. Thus, it was easier to avoid distortion to the anatomical subunits such as eyebrows and hairline. It is believed that this technique is quite appropriate for closing circular defects of scalp up to 50 mm, and temporal defects up to 40 mm. Also, Z-plasties can be added to the design when needed to increase flap rotation and decrease skin distortion.

Auricle reconstruction with a radial forearm flap prelaminated with porous polyethylene (Medpor®) implant.

Severe auricular traumas with extensive involvement of the surrounding structures present with a serious defect necessitating free tissue transfers for reconstruction. In this case report, we present a case of whole left auricle reconstruction with a radial forearm flap prelaminated with porous polyethylene (Medpor®) implant in a 17-year-old female patient. First, a subdermal pouch was fashioned on the volar aspect of the left forearm along the projection of the radial artery and the Medpor implant was placed in this pouch. Four weeks later, the prelaminated radial forearm flap containing the Medpor implant was transferred to the recipient site. Resultant construct had a pliable skin cover, and the patient was pleased with the esthetic outcome even though revisions such as external auditory meatus widening, conchal cup deepening, and lobule defining were planned as further interventions. We believe that this method is a pertinent reconstructive option for extensive defects of the auricular region.

Reconstruction of hand injuries with multiple metacarpal defects using free fibular osteoseptocutaneous flap.

Hand injuries with multiple metacarpal involvements often include midpalmar muscle, extensor tendon, and skin defects. Reconstruction method is decided according to the type and amount of structures to be restored. Bone reconstruction and resurfacing of the skin is regarded as priority, and restoration of tendon function and joint mobility can be left for further procedures. An ideal flap for such defects should provide bone for multiple metacarpal defects and a large enough skin paddle. Such flaps are few, and one of the most suitable of them all is the free fibular osteoseptocutaneous flap (free FOSCF). In this report, our experience with the use of free FOSCF for reconstruction of the mutilating hand injury in five patients with extensive skin integument and metacarpal involvement has been presented. Total lengths of fibular flaps were averagely 11 cm in length and were divided into averagely 2.4 segments. Average dimensions of the skin paddles were 7.75 × 8.75 cm. Although the nature of the devastating traumas limited the ultimate functional recovery; wound closure, stability, and various degrees of mobility were restored in all patients. In our experience, reconstruction with free FOSCF proved to be an effective tool in mutilating hand injuries with metacarpal involvement.

Finger pulp reconstruction with free dorsoulnar artery perforator (DUAP) flap.

Finger pulp is a common site for hand injuries, and pulp reconstruction is significantly important for optimal handling and sensation. Ideal substitute must provide matching texture, tenacity, and slim subcutaneous fat. This article presents six cases in which fingertip and finger pulp reconstruction were performed via free dorsoulnar artery perforator (DUAP) flap. All flaps survived and all patients healed uneventfully without any complications by the end of at least 3 months follow-up. Free DUAP flap has proved to be a suitable substitute for pulp reconstruction with its thin structure, minimally morbid donor site which is also close to the trauma zone, and possibility for neurotization. It can be especially favorable when splitting the surgical team for a glabrous flap harvest from the foot is not possible.

The Y-V-I principle for salvaging distal digit replantation.

The replantation and revascularization of a distal finger following a crush injury or avulsion are difficult because of the shortness of the vessels after debridement. The success rate of the anastomoses may decrease when they are under tension. To address this, many maneuvers have been described, such as shortening the amputated part or proximal finger stump for tensionless closing, interposing a vein graft between the vessel ends, and vessel transfer from a neighboring finger. Regardless of which of these techniques is chosen, it is an additional drawback for the already traumatized hand or amputation stump. Y-V-I pedicle lengthening is a method for providing extra pedicle length. This article presents a pediatric patient with a traumatic partial amputation at the fourth distal interphalangeal joint in whom the finger was salvaged by achieving anastomoses using the Y-V-I pedicle-lengthening principle.