Oberg-Manske-Tonkin Classification of Congenital Upper Extremity Anomalies: The First Report From Turkey.

PURPOSE: Although the Oberg-Manske-Tonkin (OMT) classification has been recommended by the International Federation of Societies for Surgery of the Hand owing to some insufficiencies of the Swanson classification system, it has not achieved a universal adoption by hand surgeons. In this study, we hypothesize that the OMT classification can be used easily to classify congenital upper extremity anomalies. We also aim to make epidemiological analysis of congenital upper extremity anomalies with the OMT classification and to compare the applicability of the OMT and the Swanson classifications. METHODS: We retrospectively analyzed 711 patients and 833 extremities operated on between 2012 and 2017. Photographs, plain x-rays, and brief medical histories of the patients were evaluated by 4 plastic surgeons. Two independent evaluations were made by each surgeon in 1-month interval using these classification systems. RESULTS: Total number of upper extremity anomalies recorded was 1050. Of the 711 patients operated on, 122 had bilateral anomalies. The anomalies were identified in 833 extremities because many extremities had more than a single diagnosis. We were able to classify all of the anomalies within the OMT classification. The OMT classification gives better reliability results compared with the Swanson classification according to intrarater and interrater reliabilities. CONCLUSIONS: Compared with the Swanson classification system based on phenotypic evaluation of the extremity, the OMT classification system is easier to apply and the association of the anomaly with the embryologic origin during evaluation is possible. We believe that multiple studies from different centers will boost the international acceptance of the OMT classification.

Comparison of Musculocutaneous and Fasciocutaneous Free Flaps for the Reconstruction of the Extensive Composite Scalp and Cranium Defects.

Composite scalp and cranium defects, which require microsurgical reconstruction, result from tumor resection, radiation, trauma, severe burn injuries, and rarely vasculitic disorders. In the current study, the authors aim to compare the outcomes of the fasciocutaneous flaps and musculocutaneous free flaps used for the reconstruction of extensive composite scalp and cranium defects. From 2010 to 2017, 21 patients who underwent composite scalp and cranium defect reconstruction with a free flap were retrospectively identified. Eighteen patients had squamous cell carcinoma, 2 patients had meningioma, and 1 patient had Ewing sarcoma. Thirteen musculocutaneous free flaps including latissimus dorsi and vertical rectus abdominis flaps and 9 free fasciocutaneous flaps including radial forearm and anterolateral thigh flaps were used. Only 1 flap loss was encountered. No neurologic impairment in postoperative period was reported. The mean length of stay in the hospital, the duration of surgery, and total volume of blood transfusion for the fasciocutaneous flap group were significantly shorter than those for musculocutaneous flap group. No flap atrophy was reported in fasciocutaneous flap group. Reconstruction of the composite scalp and cranium defects with fasciocutaneous free flaps allows shorter hospitalization, less blood transfusion and less flap atrophy than those of musculocutaneous flaps. To this respect, their usage should be prioritized in such challenging patients.

The systematic review and meta-analysis of free flap safety in the elderly patients.

BACKGROUND: Prolonged mean life expectancy gives rise to a more populated and older patient group. With increasing number of cases during the past decades, older patients are regarded as candidates for microsurgical interventions. Whether advanced patient age is an independent risk factor for microsurgical reconstruction is still an ongoing matter of debate. METHODS: The Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, CINAHL and EMBASE databases were screened for combination of the key words "elderly", "geriatric", "advanced age", "free flap", "microsurgery", free tissue transfer" by using time limits between 1989 and 2015. RESULTS: According to results of the meta-analysis, there was no significant difference in the flap success rates(P =.39, CI = 0.848 to 2.329) and surgical complication rates (P = .83, CI = 0.792 to 1.163) between the young and elderly patient groups. However, the systemic complication rates(P = .02, CI = 1.468 to 3.572), preoperative ASA scores(P < .0001, CI = 0.342 to 1.078), and mortality rates (P = .03, CI = 2.636 to 9.055) were found to be significantly higher in the elderly patients. CONCLUSIONS: Although an increased rate of systemic complications and mortality has been associated with advanced age, our study results showed no significant difference between the flap success rates and surgical complications. A successful reduction in systemic complications would bring the risk level of reconstructive microsurgical interventions of the elderly patient group to the level of the young patient group. © 2017 Wiley Periodicals, Inc. Microsurgery 37:442-450, 2017.

Microvascular Tissue Transfers for Midfacial and Anterior Cranial Base Reconstruction.

Reconstruction of a midfacial defect can represent a difficult challenge for the plastic surgeon. Although many midfacial deformities have traumatic or congenital origins, the vast majority of head and neck defects occur after resection of malignant head and neck neoplasms. Autogenous reconstruction is now routinely performed for larger, complex defects resulting from surgical resection or trauma. In this study, the authors present 27 patients with midfacial defects reconstructed with free flaps. Twenty-two of the defects were created by surgical ablation of cancer (maxillectomy) and the others were traumatic. The maxillectomy defects were classified into 4 according to the classification proposed by Cordeiro. Eighteen of the patients were male and 9 were female. Twenty-nine free flaps were performed. Six different types of flaps including radial forearm flap, vertical rectus abdominis (VRAM) flap, anterolateral thigh (ALT) flap, tensor fasciae latae (TFL) flap, fibula osteocutaneous flap, and iliac osteocutaneous flap were accomplished. Types I and II defects were reconstructed with radial forearm flap. Type III defects were reconstructed with VRAM and ALT. Type IV defects were reconstructed with VRAM and TFL. Two patients underwent a second flap reconstruction due to recurrent disease (9.1%). Average patient age was 53.1 years. Free-flap survival was 100%. Free tissue transfer is the method of choice in midfacial reconstruction. Following a reconstructive algorithm is useful in the decision-making process for patient evaluation and treatment. Every reconstructive microsurgeon might have different experiences with different flaps. Therefore, the algorithm for flap choices is not universal among surgeons.

Extracorporal Shock Wave Therapy as a Delay Procedure to Improve Viability of Zone 4: An Experimental Study in a Rat TRAM Flap Model.

BACKGROUND: The purpose of this study was to test our hypothesis that preoperative application of radial extracorporeal shock wave therapy (rESWT) as a delay procedure would improve the survival of zone 4 of transverse rectus abdominis musculocutaneous (TRAM) flap and reduce the resulting necrotic area. METHODS: Twenty-four Wistar rats were randomized and divided into 3 experimental groups (n = 8 each). Caudally based TRAM flap model, with the right rectus abdominis muscle as the carrier and right inferior epigastric vessels as the vascular pedicle, was used in this study. In group 1 (control), after being raised, the TRAM flap was sutured back to its bed without any further intervention. In group 2, the TRAM flap was raised, and rESWT was administered immediately after the flap was sutured back to its bed. In group 3, rESWT was applied 7 days before the elevation of the flap, as a delay procedure. Seven days after the administration of rESWT, TRAM flap was raised and then sutured back to its bed. RESULTS: At postoperative day 5, the mean percentage of skin flap survival was 61.82 ± 12.22 for group 1, 77.65 ± 4.62 for group 2, and 79.89 ± 5.86 for group 3. Groups 2 and 3 revealed higher survival areas when compared with control group (P = 0.02). In rESWT applied groups 2 and 3, the increase in capillary density and dilatation of microvessels in the skin flap survival areas were obvious. Histologic analysis revealed significantly higher neovascularization and less inflammation in zone 4 of rESWT applied groups (P < 0.001 and P = 0.042, respectively). CONCLUSIONS: ESWT appears to be a cheap, practical, and promising option for improving the viability of zone 4 of TRAM flap and may also be used as a delay procedure in the clinical setting.

Jejunum/DIEP Composite Flap: A Novel Rat Model of Viscerocutaneous Flap Prefabrication.

Background Reconstruction of complex pharyngoesophageal defects presents a major challenge, particularly in soft tissue deficient and previously scarred surgical sites. In recent years, the free jejunum flap method has emerged as a reliable means of esophageal reconstruction. However, it may require cutaneous coverage with an additional flap in extensively scarred, secondary reconstructions. Prefabrication of an intestinal/cutaneous composite flap can potentially solve this problem. Materials and Methods Total 28 Sprague Dawley rats were used in the study protocol. A vascularized jejunal segment was transposed beneath the deep inferior epigastric perforator (DIEP) flap. Contact with underlying abdominal fascia was prevented using a silicone sheet. Animals were distributed into five groups based on the timing of deep inferior epigastric vessel ligation to determine the time required for successful revascularization. The viability and the vascular anatomy of the prefabricated structures were analyzed using histology and microangiography. Results A jejunum/DIEP composite flap was successfully prefabricated based on mesenteric vessels. The skin component survived intact after 5 days of contact with serosal surface of the jejunal segment. Conclusion The clinical application of this technique can provide an alternative means of single-stage esophageal reconstruction, especially in patients with soft tissue deficiency and donor vessel unavailability.

Intraoral use of extraoral implants for oral rehabilitation of a pediatric patient after resection of ewing sarcoma of the mandible and reconstruction with iliac osteocutaneous free flap.

Large osseous defects secondary to resection of the mandibular segment may lead to significant facial deformity, functional disabilities, and associated psychologic problems. The therapeutic approach is more complicated in pediatric patients because it must not interfere with normal craniofacial growth process. Here, we present a clinical report to emphasize the application of extraoral short implants with magnetic abutments used for mandible of a growing patient reconstructed with free iliac flap after resection of Ewing sarcoma. A 5-year-old boy, complaining of an ulcerated mass of the anterior mandibular area and floor of the mouth, was referred to our clinic. Incisional biopsy from the lesion confirmed the diagnosis of Ewing sarcoma. After resection, free iliac osteocutaneous flap, with a 6.5 × 4.0-cm skin paddle and based on the deep circumflex iliac vessels, was used to reconstruct the mandibular integrity and to cover the floor of the mouth simultaneously. Nine months after the operation, the patient was referred for oral rehabilitation. Prosthodontic plan included the placement of 5 extraoral implants with magnetic abutment and fabrication of an implant-retained overdenture. Magnetic abutment was preferred not to interfere with the expected craniofacial growth. During a follow-up period, radiographic images showed no pathologic signs with consideration of overall bone loss and recurrence of the tumor; 12 months after the initiation of prosthetic loading, no peri-implant bone loss was observed. In conclusion, this reported case would be an example for the management of challenging pediatric mandibular tumor cases in terms of resection, reconstruction and dental rehabilitation.

Reconstruction of external auditory canal with a laterocervical twisted (snail) flap.

There are several different causes of the deformities of the external auditory canal requiring reconstruction such as tumors, burns, trauma, and malformations. Many surgical approaches with varying success for the reconstruction of the external auditory canal (EAC) have been favored, including secondary healing, skin grafting, and a variety of local skin flaps. Unfortunately, the major drawback of the previously defined techniques is the resulting stenosis of the EAC. A 73-year-old white man was admitted to our clinic because of an unhealing ulcerated lesion at the superior and posterior one third of the left external auditory canal, involving the most internal part of the concha. Preserving the superior one third of the helix, left auricle and the EAC was surgically removed en bloc. To reconstruct the surgical defect, a snail flap was designed on the ipsilateral cervical region and based posteriorly on the left mastoid region. Twisting the flap on its main axis, as mentioned, created a final shape resembling a snail and a tube with epithelium-lined canal inside. At the postoperative first-year visit, the patient's endoscopic examination showed no sign of recurrence, tympanoplasty graft was intact, and the EAC was patent without signs of stenosis. Our experience with the laterocervical flap supports the fact that this flap does not cause stenosis, hearing loss, and therefore should be concerned as one of the first choices of treatment for the reconstruction of EAC.

Evaluation of versatility and outcomes of the first dorsal metacarpal artery flap in thumb defects.

BACKGROUND: It is clinically vital to determine the best technique to reconstruct thumb defects with satisfactory esthetic and functional outcomes. We aimed to quantitatively present the safety, versatility, limitations, advantages, and functional results of the first dorsal metacarpal artery flap (FDMAF) and evaluate its outcomes in thumb defect reconstruction by comparing it with the other current surgical options. METHODS: A total of 21 patients underwent thumb defect reconstruction. They were evaluated with the following parameters: Etiology, age, timing of reconstruction, flap vitality, Semmes-Weinstein monofilament (SWM) test, static two-point discrimination (2PD) test, pain, cortical reorientation, cold intolerance questionnaire, and Michigan hand outcomes questionnaire. Their functional outcomes were evaluated by comparing their scores with the other current surgical options published in the literature. RESULTS: The mean follow-up period was 22.3 months. The mean pain score of the flap was 0.4±0.6 and no patient had pain in the donor area (range, 0-10). The sensory outcome was 'good' (8.6 mm) based on the static 2PD test. The mean SWM test score was 4.02 g. Patient satisfaction was 4.6 according to the Michigan hand outcomes questionnaire (range, 0-5). The cold intolerance questionnaire scores showed that the patients had mild cold intolerance (mean, 10.5; range 0-100). Complete cortical reorientation was seen in 81% of the patients. CONCLUSION: Restoration of the innervation of thumb defects is possible with the FDMAF with high satisfaction rates based on our results. The absence of the microsurgical vessel or nerve repair facilitates the surgery, shortens its duration, and reduces morbidity, reserving the microsurgical options for more complicated cases. Therefore, it can be concluded that the FDMAF is an effective flap with great modifications for complicated thumb defects but surgeons should consider their clinical outcomes and prolonged surgery when choosing which technique to be used.

First case report of Pacinian corpuscle hyperplasia following complex regional pain syndrome.

Pacinian disorders are exceedingly rare, and the exact pathogenesis is still unknown. The most common symptoms are pain, sensory changes, and a visible or palpable mass, and diagnosis is usually made by pathological examination after the excision of the painful nodule. In this case report, we present the case of a 49-year-old male with Pacinian corpuscle hyperplasia located on the metacarpophalangeal joint, emerging at the same hand of the patient two years after the treatment due to complex regional pain syndrome (CRPS). To the best of our knowledge, this is the first case report revealing the association of CRPS with hyperplasia of Pacinian corpuscles.

A supportive donor nerve for long-term facial paralysis: Anatomical analysis of the posterior auricular nerve and micro-anatomical comparison with zygomatic nerve.

BACKGROUND: The posterior auricular nerve (PAN) is an inspiring candidate for the additional axonal source in long-term facial paralysis to improve the functional results of the cross-facial nerve (FN) graft technique. However, no studies have analyzed the PAN's axonal load and its microscopic anatomy to assess its utilization in facial reanimation. The present study aims to examine the anatomical and microscopic features of the PAN to analyze its feasibility as a donor nerve. METHODS: The bilateral facial side of 14 fresh frozen adult human cadavers was examined for the study. The PAN's anatomical course was recorded, and nerve specimens from the PAN and zygomatic nerve (ZN) were obtained to compare their microscopic anatomy and axon counts using a light microscope and transmission electron microscope. RESULTS: The PAN's average branching distance and its course length were 5.8 ± 2.69 mm and 59.2 ± 5.85, respectively. The mean number of myelinated axons was 600.28 ± 69.97 in the PAN and 728.85 ± 166.31 in the ZN. This difference between the two nerves was statistically significant (p = 0.002). However, considering the gender variable, the mean axon counts of PAN and ZN were statistically similar for face sides and their average. Furthermore, the ultrastructural anatomy of both nerves was similar in electron microscopic evaluation. CONCLUSIONS: The present study confirms that the PAN is a proper candidate to be a supportive donor nerve due to its isolated site, consistent anatomical course, convenient ultrastructural anatomy as well as axonal load.

A new experimental reversed-flow flap model: tail artery based skin flap on the dorsum of the rat.

Reversed-flow flaps are widely preferred particularly in reconstruction of the defects of distal part of the extremities. To overcome the drawbacks faced during clinical practice of this flap type, experimental models in economical species are required. This study provides a new reversed-flow flap model on the dorsum of the rat which is supplied by the ipsilateral lateral caudal artery. It is designed as a triangle with a 4-cm long base and 5 cm long height and it is well protected from autocannibalization and environmental conditions because of its dorsal location. When compared with the present models, we believe that this simple, reproducible, and practical flap model can be considered as advantageous, and will be preferred by the researchers for future experimental studies in hemodynamics and physiology of reversed-flow flaps.

Soft-tissue management with immediate free flap transfer in segmental prosthetic replacement of proximal tibia sarcomas.

Knee reconstruction with endoprosthesis after tumor resection is accepted as superior when compared with the other methods. But sometimes soft tissue reconstruction would be a challenging problem in this way of treatment. Five patients who were operated for tumor resection in this location, followed by reconstruction were presented with their one-year post operative results. Four latissimus dorsi and one rectus abdominis myocutaneous free flaps were used in these patients in order to manage soft tissue problems. All patients underwent chemotherapy in postoperative period. All flaps were successful in one year post operative examination. In this report we would like to stress the importance of surgical planning and soft tissue reconstruction of a specific patient population. We think that large musculocutaneous flaps such as latissimus dorsi and rectus abdominis musculocutaneous flaps should be preferred in soft tissue reconstruction of knee region after tumor resection followed by prosthetic replacement. Additionally, this way of treatment is superior when compared to the other methods in order to prevent complications such as prosthesis exposure or infection.

Aneurysmal Bone Cyst of Pisiform Bone: Diagnosis and Treatment of a Rare Entity: Case Report and a Review of the Literature.

Aneurysmal bone cyst (ABC) is a benign expansile bone tumor without metastasis capability. Only 3-4% of ABCs occur in the hand and they mainly take place in metaphysis' of long bones like metacarpals or phalanges. Carpal ABCs have been reported as individual case reports in the literature due to rarity. A patient presented with pain in her right wrist. Magnetic resonance imaging revealed a well circumscribed one cm sized mass in the pisiform bone that resembled an aneurysmal bone cyst. Total pisiformectomy was performed. Treatment options are total excision or curettaging in ABCs. But rarity of these lesions may delay the diagnosis process for the inexperienced surgeon.

Comparative assessment of fingertip replantation in paediatric and adult patients within a single institution.

The purpose of this retrospective study was to compare the outcomes of paediatric and adult fingertip replantation within a single institution. Our retrospective study found no significant difference in the survival rate between the paediatric (10/12) and adult (22/26) groups. At 6 months follow-up, there was no significant difference in sensory recovery between both groups, as measured with Semmes-Weinstein testing, but a significant difference in mean static two-point discrimination testing values between the paediatric (4.0 mm) and adult (6.2 mm) groups. Moreover, the mean time for regaining sensation was faster in paediatric patients (1.3 months) as compared with adult patients (4.1 months). Five children and four adults received erythrocyte transfusion. Paediatric fingertip replantation has similar survival rates, faster and better sensory nerve recovery as compared with adults despite a higher erythrocyte transfusion rate. Although technically demanding, paediatric fingertip replantation is recommended, whenever possible, because of the good outcomes achievable.Level of evidence: IV.

Papillary intralymphatic angioendothelioma: An extremely rare tumor.

Papillary intralymphatic angioendothelioma (PILA), an intralymphatic lesion of vascular ducts, is an extremely rare tumor. It is generally encountered as an unexpected pathology following excision of a vascular skin lesion. Re-excision is the commonly preferred treatment option once the pathological diagnosis is established. In this article, we present a 12-year-old male patient with a PILA treated with re-excision, skin grafting, and sentinel lymph node biopsy. The patient was symptom-free at annual follow-up. A sentinel lymph node biopsy during re-excision might be a good option in the surgical management of PILA. Frequent examination of lymph nodes and skin lesion also might be beneficial during the follow-ups.

Gout tophus in transferred tendons after 33 years: A case report.

Surgical site gout is an extremely rare complication that is difficult to diagnose, particularly in patients without a history of gout. A 57-year-old male patient was admitted with no previous history of gout, complaining of surgical site gout located at the junction where flexor carpi ulnaris tendon was transferred to extensor digitorum communis tendon after 33 years of the initial surgery. The patient was presented with a progressive swelling over the last three months which was located on the dorsoulnar side of the right wrist joint. Magnetic resonance imaging revealed an iso/hypointense mass. During the excisional biopsy, retained non-absorbable suture materials were observed within the mass. Histopathological examination result was reported as a typical gout tophus. No recurrence was observed after 18 months of follow-up. In conclusion, surgical site gout may be observed at transferred tendons years after the initial surgery.

Co-infusion of donor bone marrow with host mesenchymal stem cells treats GVHD and promotes vascularized skin allograft survival in rats.

We investigated the effect of autologous mesenchymal stem cells (MSC) on multiple unmodified donor bone marrow (BM) infusions and vascularized skin graft outcome. BM-derived rat MSC were examined for phenotype and function. MSC/MSC-conditioned-medium suppressed IFN-gamma production by T cells and modified DC function. Infusions of MSC with one-time BM improved vascularized skin graft survival, while with one-two-times BM reversed graft versus host disease (GVHD). Mixed chimerism was enhanced in recipients given two-four-times BM with MSC infusions. Interestingly, four-times BM infusions with MSC delayed GVHD onset, reduced host tissue damage and enhanced vascularized skin allograft survival compared to four-times BM alone. These data demonstrate that, the co-infusion of MSC with unmodified BM limit the toxicity of allogeneic BM transplantation, enhance mixed chimerism and improve vascularized skin graft survival. These findings provide insights for the development of autologous MSC-based BM transplantation and prevention of graft rejection or treatment of autoimmunity.

Varenicline increases random flap survival in rats submitted to nicotine.

Smoking is a leading cause of flap failure. Varenicline-assisted smoking cessation has shown beneficial effects on vascular endothelial function. The aim of this study was to determine whether varenicline conveys beneficial effects for skin flap survival. Twenty-four rats were randomly divided into four groups of six. The rats in the control group received normal saline subcutaneous injections, and those in the nicotine group received subcutaneous nicotine injections. The rats in the varenicline group received varenicline intraperitoneally, and those in the nicotine-varenicline group received both nicotine and varenicline. At the end of week 3, the dorsal skin flaps were raised in all rats. On postoperative day 7, the flaps were evaluated by direct observation, microangiography, and light microscopy. The mean necrotic area of the flaps was significantly greater in the nicotine group than in the control group (49.2 ± 4.71 vs. 22.03 ± 0.93%, respectively, p < .01) and significantly higher in the nicotine-varenicline group than in the varenicline group (22.4 ± 1.23 vs. 9.2 ± 0.59%, respectively, p < .01). However, no significant difference was observed between the control and nicotine-varenicline groups (p = .934). Microangiographically, vascularity was lowest in the nicotine group and highest in the varenicline group. Histologically, larger areas of necrosis, more severe inflammation and less vessel formation were observed in the nicotine group. Healing, exhibited by a greater number of vessels, was evident in the varenicline-applied groups. Varenicline appears to increase the microcirculation of random flaps, as shown by decreased flap necrosis and increased vascularity.