Time-related variations in viability of random pattern skin flaps: An experimental study in rats.

Chronobiological variations are in the fabric of life. The first ideas regarding the possible effects of circadian rhythm on surgical outcomes were published in the early 2000s. Some studies support and oppose this idea. The lack of experimental evidence in a controlled setting has led to this study. This study aimed to explore the chronobiological implications of surgical outcomes. The rats were divided into four groups. A random pattern dorsal skin flaps were elevated in all groups at six h intervals. Flap necrosis rates and melatonin, oxidant, and antioxidant factors were studied. Flap survival was better in the 06:00 h group. The flap necrosis was higher in the 18:00 h group. Some of the biochemical parameters displayed circadian variations. As an independent variable, the time of surgical intervention changed the flap survival rates. It should be noted that the study was held in a nocturnal animal model thus the pattern of flap survival can be in reversed fashion in a clinical scenario. This study is the first experimental evidence for "Chronosurgery" in a controlled setting. Further studies in all aspects of surgical disciplines are required.

Reconstruction of postburn contractures due to tandir oven.

The aim of the study was to evaluate postburn contracture reconstructions caused by high temperature such as tandir. The records of our 58 patients who were operated for burn contracture between 2008 and 2018 were retrospectively reviewed. Duration elapsed after the burn, localization of contracture, surgery applied, and the recurrence rates were recorded. McCauley classification was used to evaluate the severity of hand contractures. One hundred and thirty-seven contracture release operations were performed in 45 hands in 40 cases. Five patients had bilateral hand contractures. One hundred and sixty-three (84.9%) surgeries out of total 192 contracture release surgery were applied to the hand and foot region. FTSG alone was the most common method of treatment. Z-plasty was used the most frequently by our team as the flap surgery. Tissue damage is more severe due to very high temperature of the tandir and as a result, more frequent and heavier burn contracture occurs on hands and feet than other burn etiologies develops, and reconstructive operations are needed more frequently.

A novel method for flap delay vacuum assisted flap delay: an experimental study in rabbits.

Flaps are the workhorse of plastic surgery practice. The delay procedures have been defined to prevent flap necrosis. The golden standard method of delay is a surgical delay. On the other hand, a major drawback of surgical delay is two sessions of surgery. Efforts have been made to omit one session and increase the patient safety and decrease the costs. The writer's aim was to evaluate the effects of topical negative pressure, applied prior to flap elevation, on flap survival, perfusion and compare the results with the surgical delay. In a rabbit random flap model, prior to elevation, the writers used a topical negative pressure system on the lateral thoracic region of, for induction of delay and compared the results with surgical delay and the control group. The total and necrotic flap areas, necrosis ratio, histomorphometric vascular density, immunohistochemical evaluation of neovascularization (CD31/CD34), Laser Doppler images and computerized tomography contrast uptake were used to compare the groups. In all of the parameters, the vacuum assisted flap delay was equivalent to surgical delay. Both were superior to non-delayed flaps. Control group had 65.56 ± 18.02% flap necrosis rate, while Surgical Delay group had 37.31 ± 30.74% and Vacuum Assisted Flap Delay group had 19.58 ± 27.35%. Vacuum Assisted Flap Delay did not require an extra operation for the delay procedure. The mechanism of action in the vacuum-assisted flap delay is unclear. The clinical significance should be studied further. However, vacuum assisted flap delay seems to be a promising method in the clinical setting.

Chimeric Reverse Temporal Muscle and Pericranial Flap for Double-Layer Closure of Deep Facial Defects.

PURPOSE: Volumetric or multiplane defects of the upper and midface remain a challenge for reconstruction because of limited regional flap options. In this study, the authors harvested the reverse temporalis muscle flap and pericranial flap (RTMP flap) based on the same vascular pedicle, the superficial temporal artery, in a chimeric manner to obtain double-layer closure of deep facial defects. MATERIALS AND METHODS: This study was a prospective case series performed in the Department of Plastic Surgery of Ataturk University (Erzurum, Turkey). The outcomes, including flap survival, postoperative complications, reconstructive success, esthetic appearance, and donor site morbidity, were clinically evaluated. RESULTS: Fourteen patients (10 male and 4 female) with deep defects of the middle third of the face underwent reconstruction using the chimeric RTMP flap. All chimeric RTMP flaps survived without postoperative complications. All defects were successfully repaired and covered with chimeric RTMP flaps. Patients were satisfied with the esthetic results. CONCLUSION: The chimeric RTMP flap is a good reconstruction option and can be used safely for moderate to large 3-dimensional defects of the middle and upper face. Smooth and durable coverage over the bulky muscle flap used to fill the volume defect and a larger flap for larger volume defects can be obtained by including the pericranial segment of the chimeric RTMP flap.

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.

Factors affecting adherence to treatment and follow-up of burns in children: A single centre experience.

AIM: Children are prone to burn injury. Burns can be seen as a part of child abuse. The aim of this study was to investigate the factors affecting adherence to the treatment of burn patients, and to emphasize the role of the physician in identifying children's non-accidental burn injuries. MATERIALS AND METHODS: Children who were hospitalized in the burn unit were analyzed retrospectively. Results were assessed for significance using the Chi-square test. RESULTS: A total of 189 patients were included. Some patients (n = 52; 27.5%) were discharged against medical advice (DAMA) before completion of treatment. Although we could not demonstrate a relationship between non-accidental etiology and DAMA group, it was significant that these patients did not contact the outpatient clinic after discharge. It was evident from records that two of these cases were abused. The reasoning of the parents in the DAMA group for the early discharge was siblings at home, financial and accommodation problems. CONCLUSION: Although burns in children commonly occur due to an accident, each burn case should be examined for a non-accidental etiology and findings suggesting abuse should be noted. Physicians should be alert for the detection of signs of burn related child abuse.

A radioanatomic study of the internal mammary artery and its perforators using multidetector computed tomography angiography.

The Internal Mammary Artery (IMA) and its perforators play an important role in coronary bypass grafting and reconstructive breast, head, and neck surgery. This study aimed to obtain anatomic data pertaining to these vessels using Multi Detector Computed Tomography Angiography (MDCTA) and to demonstrate that the MDCTA could be a considerable assessment tool prior to surgery. In 50 outpatients (27 males and 23 females), the above-mentioned arteries were bilaterally evaluated with a 16-detector spiral computed tomography scanner. Based on the obtained images, diameters of the bilateral IMAs were separately measured in each intercostal spaces from 1 to 5 through their traces. IMAPs greater than 0.5 mm in diameter were bilaterally evaluated in terms of distance from the sternal border to the ramification point under the muscular layer, maximal external diameter at ramification from the IMA, and the length between the ramification point from the IMA and enter point to the subcutaneous fat tissue. Mean diameters of the left and right IMAs were 2.05 ± 0.50 mm and 2.20 ± 0.57 mm, respectively. Mean diameters, distances, and lengths of the perforators were 1.30 ± 0.30 mm, 6.80 ± 3.40 mm, 17.05 ± 6.07 mm on the left side and 1.32 ± 0.25 mm, 6.71 ± 3.43 mm, 17.35 ± 3.48 mm on the right side, respectively. No statistically difference was found between the sides (P > 0.05). About 20 of 36 perforators appeared in the second intercostal space, whereas there were eight in the first and eight in the third intercostal space. MDCTA, as a non-invasive vascular imaging method, can be a valuable tool for investigating the anatomic characteristics of the IMA and its perforators before planning an operation.

Latissimus dorsi flap harvest with a short incision.

Latissimus dorsi (LD) flap is one of the most common options utilized in reconstructive armamentarium. In this report, we present our experience on harvest of the full LD muscle flap through a short incision. Twelve free and two pedicled full LD muscle flaps were raised in 14 patients (9 males and 5 females). In this technique, an oblique incision was placed 5-7 cm caudal to axillary apex, beginning from the posterior axillary line, so as to center the neurovascular hilus. The length of incision was 10 cm in adults and 8 cm in children. Mean dissection time was 45 min. All flaps survived totally. Seroma formation developed in two cases and treated with syringe aspiration and compressive dressing. In late postoperative period, donor site scars became inconspicuous and patient satisfaction was high. Short incision technique may be a good option to overcome scar problems in donor site of the LD flap. The technique reduces the dissection time and does not require sophisticated surgical devices and skill, when compared to endoscopic LD flap harvesting from the literature.

Hunter's technique without Hunter's rod.

Silicon rods initially advocated by Hunter have been widely used in two-stage flexor tendon reconstruction. Two-stage tendoplasty is an expensive procedure; with the addition of the high cost of rods, it is still more expensive. An experimental study investigated cheaper alternatives to silicon rods, but no clinical studies seem to have been reported so far. This study involved 17 patients undergoing two stage flexor tendon grafting. In all fingers, silicon urinary catheters were used as tendon prosthesis. The Wehbe et al modification of the Boyes and Stark classification was used for preoperative classification and Strickland formulation and Buck-Gramcko criteria for postoperative analysis. This clinical study showed that comparable clinical results and proper pseudosheaths for tendon grafting with similar histological and physical features can be obtained using a silicon urinary catheter which is fifty times less costly than Hunter's rod.

Maxillofacial fracture experiences: a review of 152 cases.

OBJECTIVE: The fractures of facial structures lead to great morbidity. Cross-sectional studies are needed to evaluate the current state of maxillofacial traumas. Thus, this study aims to evaluate these experiences and to compare these results with the current literature. MATERIALS AND METHODS: The medical records of the maxillofacial fracture cases hospitalized between January 2004 and November 2011 were examined. The age, sex, etiology, fracture localization and treatment method for each case were documented. The affected facial bones were grouped as mandible, maxilla, zygoma, naso-orbitoethmoid complex (NOEC) and blow-out. Nasal fractures were excluded. The cases were assigned to 3 groups with respect to age (below 16, above 65 and between 17 and 64). The chi Square test was used to assess the significance of the difference in mandibular fracture rates in the pediatric population compared to others. RESULTS: The total number of cases was 152. The total number of fractures was 185. Of the 152 cases, 117 were male and 35 were female. The average age was 31.4 (±18.3), ranging between 2 and 81. Thirty-one cases were 16 years old or less. Nine cases were 65 years old or more. Mandibular and zygomatic fractures were the most prevalent fractures in the adult group. Mandibular fractures were significantly more common in the pediatric age group compared to rest of the population (X(2), p<0.05). Traffic accidents were the most common etiological factor, with a 55.3% ratio. Open reduction and internal fixation was the most frequently conducted treatment modality in all age groups. CONCLUSION: Retrospective studies are important for the projection of future prospects. In summary, our results indicate that pediatric fractures are mostly in the lower face and usually affect the condylar region, which is consistent with the literature.

Relationship of serum paraoxonase enzyme activity and thermal burn injury.

OBJECTIVE: This study investigated changes in serum oxidative stress parameters in burn cases compared to healthy controls. MATERIALS AND METHODS: This study was performed in 41 burn patients with mild to severe thermal burn injuries and 38 healthy volunteers. The burn cases were selected from patients who were hospitalized in the burn unit for the treatment of second- and third-degree burns. Malondialdehyde (MDA) levels and PON-1 paraoxonase and arylesterase activities were measured in patient serum samples. RESULTS: PON-1 paraoxonase activity and MDA levels in patients with major thermal burn injury were significantly higher than healthy controls, but PON-1 arylesterase activities were lower. A significant negative correlation was observed between the burn percentage of the total body surface area and the PON-1 arylesterase activities in patients. CONCLUSION: Human thermal burn injury was associated with an increase in MDA production and a decrease in PON-1 arylesterase activity, which was proportional to the percentage of total burned surface area.

Versatile use of rhomboid flaps for closure of skin defects.

OBJECTIVE: The aim of this study is to present our clinical experience with rhomboid flaps. MATERIALS AND METHODS: Twenty-four patients who were operated on between January 2006 and October 2010 were included in the study. All defects were reconstructed using rhomboid flaps. RESULTS: Twenty-four patients were operated on for various reasons, and 26 rhomboid flaps were performed. Eleven of the 24 cases were male, and the median age of participants was 47.5 years. Eight cases were operated on under general anesthesia, and 13 were locally anesthetized; the remaining cases were operated on under regional anesthesia. In 17 cases, the defect was due to a benign or malignant tumor excision, and five cases were operated on due to burn contracture. There were no occurrences of partial or total flap necrosis or hematoma in our series. CONCLUSION: Our series indicates that rhomboid flaps can be safely used to reconstruct small to moderately sized skin defects.