Unexpected outcome of a modification of Bracka repair for proximal hypospadias: High incidence of diverticula with flaps

INTRODUCTION

Various graft and flap techniques have been proposed for urethral reconstruction in proximal hypospadias repair. The Bracka repair involving the transfer of inner prepuce like a Wolfe graft mostly results in satisfactory results besides a high fistula rate.

AIM

The aim was to decrease the high fistula rate with Bracka repair; we wanted to use the advantages of vascularized skin in the Bracka method. The aim of this study was to evaluate our results with this modification.

STUDY DESIGN

Our modification involves using a flap instead of a graft. In the first stage, chordee was corrected by transection of the urethral plate and dorsal midline plication when necessary. Instead of a graft as suggested by Bracka, inner preputial skin with ample blood supply was transferred and stitched to the denuded ventral penile surface. In the second stage after 6 months, this flap was tubularized in the Thiersch-Duplay fashion. Hospital records of patients who had undergone two stage modified Bracka repair between June 2007 and July 2012 were reviewed, including complaints, complications, and need for interventions.

RESULTS

Thirty-eight patients had undergone this operation. Four patients were lost to follow-up. The main complaint was obstructed urinary flow. Voiding symptoms were first attributed to urethral stenosis, but were, however, found to be due to diverticulum and vortex of the urine in the dilated urethra. Twenty-one patients (61%) had voiding problems and 10 patients (29%) had urinary tract infections. Fistula was observed in 23 and diverticula were observed in 24 patients. Of these, 16 patients had both fistula and diverticula. Only two patients (5%) were free of complications and totally satisfied with the operation, and 23 of the 34 patients had complications requiring intervention (Figure).

DISCUSSION

Inner preputial flaps used in proximal hypospadias repairs are prone to diverticula formation. They become redundant in time requiring reoperation, thus decreasing the success rate. Careful fixation of the flap to the corpora and allowing time for additional attachment of the urethral plate substitution through fibrotic activity could not overcome this complication.

CONCLUSION

Our modification of the Bracka technique using a flap for the plate resulted in a high rate of complications (in particular diverticulum formation) and was therefore abandoned. We recommend careful use of flaps in hypospadias surgery and long-term follow-up studies to evaluate actual functional and cosmetic results.

Efficacy of Liposuction as a Delay Method for Improving Flap Survival

BACKGROUND

Flaps are often used in repairing tissue defects and partial or full flap loss is still an important morbidity cause. Several techniques have been tried to increase flap circulation but none of these could replace the delay technique. Our goal in this study is to show the efficacy of liposuction in delay of dorsal rat cutaneous flaps and improvement in flap survival.

METHODS

Twenty-four Wistar rats were used. The rats in group 1 received 9 × 3-sized caudally-based random pattern skin flaps. In group 2, liposuction was done under the tissue island spotted as the flap and after 14 days, standard flap surgery was done. In group 3, surgical delay was done and after 14 days, standard flap surgery was done. In group 4, liposuction was done under the tissue island spotted as the flap and standard flap surgery was done right after the liposuction.

RESULTS

The rate of necrotic tissue in group 3 (surgical delay; mean % 13.7) was less than the rate in group 2 (liposuction delay; mean % 15.1), although the difference was not statistically significant. The necrosis rates in group 3 (surgical delay) and group 2 (liposuction delay) were less than the rates in both group 1 (only flap; mean % 41.5) and group 4 (liposuction flap; mean % 40.0) and this difference was statistically significant (p < 0.0001).

CONCLUSION

Liposuction can be an alternative to surgical delay as a less invasive method in the clinic.

NO LEVEL ASSIGNED

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 .

Protective effect of tunica albuginea incision with tunica vaginalis flap coverage on tissue damage and oxidative stress following testicular torsion: Role of duration of ischemia

OBJECTIVE

This experimental study used a rat model to investigate the effect of a tunica albuginea incision with tunica vaginalis flap coverage on tissue damage and oxidative stress caused by testicular torsion and its relationship with the duration of ischemia.

MATERIALS AND METHODS

The test animals were divided into the following groups: G1, sham procedure; G2, testicular torsion for 1, 5, or 9 h followed by detorsion; G3, testicular torsion for 1, 5, or 9 h followed by detorsion using flap technique. Testicular torsion was induced by 720° counterclockwise rotation of the left testis. After the period of torsion, the flap technique was employed for detorsion. The oxidative stress and testosterone levels were measured at 24 h post procedure. Further assessment was carried out by histomorphometry at 30 days post procedure. The histological parameters included the Johnsen score, diameter of the seminiferous tubules, and thickness of seminiferous tubule epithelium.

RESULTS

The histological parameters in the G2 group showed a significant change in relationship with the duration of ischemia. In the G3 group, flap coverage improved the histological parameters only for the 9-hour torsion subjects. The levels of testosterone, glutathione peroxidase (GPX), and superoxide dismutase significantly decreased in all subgroups of G2 and G3, and the malondialdehyde level increased as the duration of ischemia increased. Flap coverage decreased the malondialdehyde level only in the 9-hour torsion subjects.

CONCLUSIONS

Flap coverage reduced tissue damage as the duration of ischemia increased. The findings of the rat model suggested that a tunica albuginea incision with tunica vaginalis flap might have provided a protective effect in long-term ischemia.

Pre-expanded Thoracodorsal Artery Perforator Flap

The size of the thoracodorsal artery perforator (TDAP) flap or pedicle, in general, may be found to be inadequate. Pre-expansion of the flap before harvest can be a solution to increase the size of the TDAP flap in such instances. The pre-expanded TDAP flap can be used to reconstruct large-sized defects with the advantage of primary closure of the donor site. This article presents details on the surgical technique and provides discussion of the authors' experiences.

The postauricular fasciocutaneous flap with an adipofascial extension: A case report

•

The postauricular flap has never been used with an adipofascial extension.

•

We present a case with an ear defect covered with this flap.

•

The indications and blood supply of the flap are discussed.

Introduction

A complex defect on the anterior surface of the ear requires flap cover; such as the postauricular skin flap. The postauricular skin flap has never been used with an adipofascial extension.

Presentation of case

A 5-year old boy was involved in a car accident resulting in an exposed cartilage of the upper part of the right ear. The defect was covered with a post-auricular fasciocutaneous flap with an adipofascial extension. The adipofascial part of the flap was covered with a skin graft.

Discussion

The adipofascial extension serves two purposes: Firstly, it allows easier primary closure of the donor site. Secondly, it is less bulky and hence it does not observe the definition of the ear cartilage.

Conclusion

Our case is the first case reported in literature using the post-auricular fasciocutaneous flap with an adipofascial extension.

Secondary free-flap reconstruction following ablation for acute invasive fungal sinusitis

OBJECTIVE

Acute invasive fungal sinusitis (AIFS) is a frequently fatal infection for which extensive and debilitating surgical debridement is a mainstay of therapy. Resulting defects are often composite in nature, mandating free tissue-transfer reconstruction. Outcomes data for free flap reconstruction are limited. The purpose of this study was to examine surgical outcomes and survival in patients undergoing free flap transfer following invasive fungal sinusitis.

STUDY DESIGN

Retrospective case series.

METHODS

Between 1995 and 2015, patients undergoing operative debridement for AIFS were identified. Surgical records were used to identify survivors of acute infection who subsequently underwent free flap reconstructive surgery. Patient demographics, cause of immune compromise, defect description, flap type, perioperative complications, indications for revision surgery, functional outcomes, and long-term survival were reviewed.

RESULTS

Forty-four patients were treated for AIFS, of those, 30 (68%) survived acute infection. Ten patients underwent maxillectomy, six with orbital exenteration, and were designated candidates for reconstruction. Eight patients underwent reconstruction. Median time from debridement to reconstruction was 67.5 days. Flap types included latissimus dorsi, scapula, anterolateral thigh, rectus, radial forearm, and fibula. Median follow-up was 7.7 months. No perioperative complications were encountered, and all subjects remained disease-free, able to speak and eat normally without prosthetic supplementation. Seven patients (87%) are currently alive.

CONCLUSION

Reconstruction of defects left by invasive fungal sinusitis using free-tissue transfer resulted in successful flap survival, with no disease recurrence for all defects and flap types reviewed. Survivors of AIFS are able to tolerate midface reconstruction, with favorable functional outcomes and survival rates.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:815-819, 2017.

[Pediatric lower extremity reconstruction]

Lower limb multi-tissular injuries are rare in children but require elaborate surgical care considering the child's growth potential, donor-site morbidity and the psychological consequences for the child and his family. This review outlines the various coverage options, from simple to more complex, developing their principles and their results. Technical features of wound repair of the lower limb in children will be detailed. An efficient and ambitious care can give excellent functional outcomes in children, even when extended, multi-tissue lesions members are involved.

Safety and efficacy of the keystone and rhomboid flaps for immediate reconstruction after wide local excision of non-head and neck melanomas

Background

After wide local excision of cutaneous melanoma, large defects not amenable to simple primary closure are often covered with skin grafts. We report our experience using the rhomboid and keystone flaps to immediately close large axial and extremity wounds after potentially curative surgery for non-head and neck melanomas.

Methods

Between January 2011 and September 2016, demographic, operative, pathologic, and outcome data were prospectively collected on 60 patients who underwent wide local excision of melanoma followed by immediate flap reconstruction. Flaps were of either rhomboid or keystone type. Chi-square analysis was used to compare relationships between factors.

Results

All procedures were done by the senior author and as outpatient surgery. No patient required a surgical drain unless they were undergoing concomitant radical regional node dissection. Flap separation (arbitrarily defined as a >5-mm dehiscence of the suture line) occurred in 16/61 patients (26 %). No patient had flap loss. The risk of flap morbidity was significantly higher if the primary tumor was on the distal extremity—10 of 24 patients (42 %), all with keystone flaps—than if it was on the trunk or the proximal extremity (6/37 patients, 16 %), p = 0.04. There were no margins positive for either invasive or in situ melanoma in the entire cohort.

Conclusions

Simple transposition flaps can successfully cover large defects after melanoma excision without the need for skin grafting. Keystone flaps in the distal extremity are more prone to separation, but this is minor and does not result in flap loss. There is minimal risk of a positive margin requiring flap takedown and a second re-excision.

A molecular dynamics study of the BACE1 conformational change from Apo to closed form induced by hydroxyethylamine derived compounds

BACE1 is an aspartyl protease which is a therapeutic target for Alzheimer's disease (AD) because of its participation in the rate-limiting step in the production of Aβ-peptide, the accumulation of which produces senile plaques and, in turn, the neurodegenerative effects associated with AD. The active site of this protease is composed in part by two aspartic residues (Asp93 and Asp289). Additionally, the catalytic site has been found to be covered by an antiparallel hairpin loop called the flap. The dynamics of this flap are fundamental to the catalytic function of the enzyme. When BACE1 is inactive (Apo), the flap adopts an open conformation, allowing a substrate or inhibitor to access the active site. Subsequent interaction with the ligand induces flap closure and the stabilization of the macromolecular complex. Further, the protonation state of the aspartic dyad is affected by the chemical nature of the species entering the active site, so that appropriate selection of protonation states for the ligand and the catalytic residues will permit the elucidation of the inhibitory pathway for BACE1. In the present study, comparative analysis of different combinations of protonation states for the BACE1-hydroxyethylamine (HEA) system is reported. HEAs are potent inhibitors of BACE1 with favorable pharmacological and kinetic properties, as well as oral bioavailability. The results of Molecular Dynamics (MD) simulations and population density calculations using 8 different parameters demonstrate that the LnAsp289 configuration (HEA with a neutral amine and the Asp289 residue protonated) is the only one which permits the expected conformational change in BACE1, from apo to closed form, after flap closure. Additionally, differences in their capacities to establish and maintain interactions with residues such as Asp93, Gly95, Thr133, Asp289, Gly291, and Asn294 during this step allow differentiation among the inhibitory activities of the HEAs. The results and methodology here reported will serve to elucidate the inhibitory pathway of other families of compounds that act as BACE1 inhibitors, as well as the design of better leader compounds for the treatment of AD.

A novel technique for repair of mid-penile hypospadias using a preputial skin flap: results of 110 patients

BACKGROUND

Several techniques have been used to repair mid-penile hypospadias; however, high failure rates and major complications have been reported. In this study, we describe a novel technique using a well-vascularized flap of the inner and outer preputial skin.

METHODS

A total of 110 male children with hypospadias underwent repair by our technique between 2008 and 2015. The inclusion criteria were children with mid-penile or slightly more proximal hypospadias, with or without ventral chordae, and an intact prepuce of the cobra eyes variety. Recurrent cases, patients with other preputial types, and circumcised children were excluded from this study. The prepared flap was sutured in its natural longitudinal orientation to the created urethral plate strip to form a neo-urethra over a urethral catheter. Outcome measures included surgical success without the formation of a urethra-cutaneous fistula, no ischaemia of the flaps, glans dehiscence or infection and functional outcome and cosmetic appearance.

RESULTS

The median follow-up duration was 3.3 years. There were 63 cases of mid-penile hypospadias (57.3 %), and in 47 cases (42.7 %), the meatus was slightly more proximal. The age of the patients ranged from 1.1 to 8.0 years, with a mean age of 4.6 ± 1.2 years. Surgery was successful in 106 (96.4 %) cases. Minor complications occurred in 11 patients (10 %) and included oedema of glans in ten patients and bluish discoloration on the ventral aspect of the glans close to the suture line in three patients. All patients improved within 2 weeks after surgery. Long-term follow-up revealed a properly functioning urethra with a forward, projectile, single, compact, and rifled urinary stream of adequate calibre and cosmetically acceptable repair. No cases of meatal retraction, meatal stenosis, urethral stricture, or acquired urethral diverticulum occurred.

DISCUSSION

Our technique is different from the split prepuce in situ technique. We create a narrow strip of the urethral plate that facilitates glanular closure, and we use the inner and adjacent outer skin in a vertical manner to preserve excess skin for penile coverage. Prepuce is split at midline to preserve more preputial skin with favourable dartos tissue for penile skin coverage. The glans is closed using a stitch-by-stitch method that has not been described previously.

CONCLUSION

This study presents a novel technique for mid-penile hypospadias repair using a preputial skin flap with excellent results in terms of short- and long-term outcomes.

"United Pedicle Flap" for management of multiple gingival recessions

Numerous surgical procedures have evolved and are being modified with time to treat gingival recession by manipulating gingival or mucosal tissues in various ways. However, the decision to choose the most appropriate technique for a given recession site still remains a challenging task for clinicians. Mucogingival deformities such as shallow vestibule, frenal pull, or inadequate attached gingiva complicate the decision and limit the treatment options to an invasive procedure involving soft tissue grafts. The situation is further comprised if there is a nonavailability of adequate donor tissue and patients' unwillingness for procedures involving a second surgical site. In such situations, the recession either remains untreated or has poor treatment outcomes. This case report presents a modified pedicle graft technique for treatment of multiple gingival recessions with shallow vestibule and inadequate attached gingiva. The technique is a promising therapeutic alternative to invasive surgical procedures such as soft tissue grafts for treatment of multiple gingival recessions.

Free Flap Functional Muscle Transfers

Free functional muscle transfers remain a powerful reconstructive tool to restore upper extremity function when other options such as tendon or nerve transfers are not available. This reconstructive technique is commonly used for patients following trauma, ischemic contractures, and brachial plexopathies. Variable outcomes have been reported following free functional muscle transfers that are related to motor nerve availability and reinnervation. This article highlights considerations around donor motor nerve selection, dissection, and use of the gracilis muscle, and the surgical approach to performing a free functional muscle transfer to restore elbow flexion and/or digit flexion.

A unilateral septal flap based on the anterior ethmoidal artery (Castelnuovo's flap): CT cadaver study

OBJECTIVE

We describe our experience for repair septal perforation with a septal flap and we analyse the route of the septal branch of the anterior ethmoidal artery (AEA) in the septum area with a radiological anatomy study in order to perform this flap.

STUDY DESIGN

We carry out a prospective analysis with computed tomography scan in the cadaver heads and we perform an endoscopic technique in the patients.

METHODS

Ten nasal cavities were analysed in five adult cadaveric heads and two patients diagnosed with anterior septal perforation were surgically treated. Measurements in the cadaveric heads were obtained from a sagittal plane of the nasal septum. The anterior point corresponds to the projection of the anterior insertion of the middle turbinate in the frontal process of the maxilla over the nasal septum. The posterior point was obtained with a vertical line passing through the entrance of the AEA in the nasal septum.

RESULTS

The mean distance between the anterior point and the posterior point was 7.35 mm with a standard deviation of 0.95 mm. The lowest value was 5.5 mm and the highest value was 8.7 mm. We observed good epithelialisation and closure of the perforation in all patients.

CONCLUSION

The unilateral septal flap pedicle by anterior ethmoidal artery may be used for small and medium perforations with a pedicle smaller than 1 cm posterior to the axilla.

Effect of botulinum toxin A and nitroglycerin on random skin flap survival in rats

BACKGROUND

A suitable pharmacological substitute for the well-established surgical delay technique for random skin flaps to increase viability has been elusive.

OBJECTIVE

To evaluate the effects of nitroglycerin and botulinum toxin type A on random flap survival in a rat model.

METHODS

The present controlled experimental study was performed in the four groups of rats. One week after intervention in each group, the flap was raised and kept in situ, and flap necrosis was evaluated through follow-up. Group 1 received intradermal botulinum toxin type A (BTX-A) and topical nitroglycerin 2%; group 2 received BTX-A and topical Vaseline (Unilever, USA); group 3 received topical nitroglycerin and intradermal normal saline; and group 4 received topical Vaseline and intradermal normal saline.

RESULTS

BTX-A reduced the area of necrosis compared with control (24% versus 56% respectively; P<0.001). Nitroglycerin application was associated with a trend toward improved flap viability (42% versus 56%; P=0.059). The combination of topical nitroglycerin and BTX-A, compared with Vaseline and BTX-A, was associated with decreased flap necrosis (16.1% versus 24%, respectively), although it was not statistically significant (P=0.45).

CONCLUSIONS

BTX-A was effective in reducing distal flap necrosis. The effect of BTX-A was significantly more pronounced than nitroglycerin ointment.

Anatomic study of the musculus longus capitis flap

PURPOSE

To clearly delineate the anatomy of the musculus longus capitis, determine its clinical applications for reconstruction surgery, and provide a safer surgical method of developing the longus capitis muscle flap.

METHODS

Anatomical investigations were performed in seven adult cadavers (five cadavers for gross anatomy and two for transparent specimen preparation) with respect to the location, morphology, arterial supply, and innervation of the musculus longus capitis, as well as its spatial relationship with the cervical sympathetic trunk, superior cervical ganglion, carotid sheath, and other surrounding structures.

RESULTS

The musculus longus capitis is located anterior to the C1-6 vertebrae, segmentally supplied by branches of the ascending cervical artery, innervated by the C1-5 nerve, and spatially close to the cervical sympathetic trunk, superior cervical ganglion, and carotid sheath. These anatomic findings indicate that the development of a cranial or caudal pedicled longus capitis muscle flap is feasible.

CONCLUSION

The musculus longus capitis can be developed into a cranial or caudal pedicled flap for repair of head and neck defects with negligible morbidity of the donor site.

Postoperative negative pressure therapy significantly reduces flap complications in distally based peroneus brevis flaps: Experiences from 74 cases

BACKGROUND

The distally based peroneus brevis muscle flap is a valuable therapeutic option for coverage of tissue defects around the ankle and the distal lower leg. However, the rate of postoperative flap complications requiring revisional surgery is high due to an impaired venous drainage and oedema formation. The purpose of this study was to evaluate if postoperative negative pressure therapy is able to reduce flap complications.

METHODS

From April 2010 until March 2014, we treated 74 patients with distally based peroneus brevis muscle flaps for defect coverage at the lower leg. In four cases, an osteomuscular composite flap has been used to treat partly stability-relevant bone defects. In 43 cases, negative pressure therapy (75mmHg, continuous) with a circular dressing was initiated after the flap procedure for 7 days. In 31 cases no negative pressure therapy was initiated. We retrospectively analysed those two groups of patients. The primary endpoint was the incidence of flap complications with a need for revision surgery, which were classified in three grades.

RESULTS

The group treated with negative pressure therapy had significantly less flap complications when compared to the control group (p<0.0001). Concerning the single grades of complication, the negative pressure therapy-group had a significantly smaller rate of skin graft necrosis (Grade 1; p=0.014) and partial flap loss (Grade 2; p=0.002) compared to the control group. There were no statistically significant differences concerning complete flap loss (Grade 3) between both groups.

CONCLUSION

Postoperative negative pressure therapy for 7 days reduces flap complications in distally based peroneus brevis flaps.

Measurement of Bone Flap Surface Area and Midline Shift to Predict Overall Survival After Decompressive Craniectomy

BACKGROUND

There is uncertainty about the optimal method for measuring the decompressive craniectomy (DC) surface area and how large the DC should be.

METHODS

A radiological technique for measuring the surface area of removed bone flaps in a series of 73 DCs was developed. Preoperative and early postoperative computed tomography scans of each patient were evaluated. Midline shift (MLS) was considered the key factor for successful DC and was assigned to either normal (0-4 mm) or pathological (≥5 mm) ranges. The association between postoperative MLS and patient survival at 12 months was assessed.

RESULTS

Measurements of all removed bone flaps yielded a mean surface area of 7759 mm². The surface area of the removed bone flap did not influence survival (surviving 7643 mm² vs. deceased 7372 mm²). The only factor associated with survival was reduced postoperative MLS (P < 0.034). Risk of death was 14.4 (3.0-70.1)-fold greater in patients with postoperative shift ≥5 mm (P < 0.001).

CONCLUSION

The ideal surface area for "large" square bone flaps should result in an MLS of <5 mm. Enlargement of the craniectomy edges should be considered for patients in whom MLS ≥5 mm persists according to early postoperative computed tomography scans.

Nasolabial Flap in Maxillofacial Gunshot Trauma: A Case Series

Introduction

The nasolabial flap (NLF) has many advantages in oromaxillary reconstruction, but the majority of cases are reconstructions after pathologic resections. Its usage in trauma surgery, especially in the management of gunshot wounds, is rarely mentioned.

Case Presentation

Three cases involving gunshot injuries to the face are presented: one for reconstruction of the nasal ala, another for bone graft coverage in mandibular reconstruction, and the third for the repair of premaxillary hard and soft tissue avulsive defects.

Conclusions

The NLF is a thin, pliable flap and is useful for intraoral and facial reconstruction of trauma patients with small to moderate soft tissue loss.

Rotational flaps in oncologic breast surgery. Anatomical and technical considerations

Local flaps are a group of surgical procedures that can solve the thoracic closure of large defects after breast cancer surgery with low morbidity. Its use in skin necrosis complications after conservative surgery or skin sparing mastectomies facilitates the initiation of adjuvant treatments and reduces delays in this patient group. This article describes the anatomical basis for the planning of thoracic and abdominal local flaps. Also, the application of these local flaps for closing large defects in the chest and selective flaps for skin coverage by necrosis in breast conserving surgery.

Random Pattern Vertically Oriented, Partial Thickness Buccinator Myomucosal Flap for Intraoral Reconstruction:A Report of Two Cases

INTRODUCTION

Reconstruction of the oral cavity with a flap design containing the buccal mucosa and buccinator muscle but excluding the facial artery and vein is the topic of these case reports.

CASE REPORTS

This article uses random pattern vertically oriented partial thickness buccinator myomucosal flap for intraoral reconstruction in two cases. The first was for lining the mandibular anterior vestibule in a trauma patient. The second was for oral side coverage of bone graft in special cleft patient. In both patients, this flap survived and good bone coverage with non-keratinized mucosa was obtained.

CONCLUSION

Thin long buccal myomucosal flap not including facial artery and vein can survive.

Planning digital artery perforators using color Doppler ultrasonography: A preliminary report

Digital artery perforator (DAP) flaps have been applied for the coverage of finger soft tissue defects. Although an advantage of this method is that there is no scarification of the digital arteries, it is difficult to identify the location of the perforators during intraoperative elevation of the DAP flap. In this study, anatomically reliable locations of DAPs were confirmed using color Doppler ultrasonography (US) in healthy volunteers. A successful case using an adiposal-only DAP flap for the coverage of a released digital nerve using preoperative DAP mapping with color Doppler US is also described. A total of 40 digital arteries in 20 fingers of the right hands of five healthy volunteers (mean age: 32.2 years old) were evaluated. The DAPs were identified using color flow imaging based on the beat of the digital artery in the short axial view. In total, 133 perforators were detected, 76 (an average of 3.8 per finger) arising from the radial digital artery and 57 (an average of 2.9 per finger) arising from ulnar digital artery. Sixty-three perforators (an average of 3.2 per finger) in the middle phalanges and 70 (an average of 3.5 per finger) in the proximal phalanges were found. Overall, an average of 1.7 perforators from each digital artery was detected in the proximal or middle phalanges. Moreover, at least one DAP per phalanx was reliably confirmed using color Doppler US. Preoperative knowledge of DAP mapping could make elevating the DAP flap easier and safer.

[Plastic surgery treatment techniques for interdisciplinary therapy of pressure sores]

Pressure sores in geriatric patients represent a challenge for all disciplines involved in the treatment process; however, the prerequisite for successful treatment is the elaboration of an interdisciplinary treatment concept. The treatment goals should be adapted to the individual needs of the patients including the life situation, general condition and local findings. In addition to general basic operative techniques, such as wound cleansing and conditioning, plastic and reconstructive surgery provides a wide range of highly specialized operative techniques for the treatment of these patients by which a definitive defect coverage can be achieved. The aim of this article is to raise awareness for these complex and highly specialized procedures for all disciplines participating in the treatment in order to improve the interdisciplinary cooperation and ultimately the quality of treatment.

High-Pressure Water Swelling Sealant Injection Injury to the Hand: a Case Report and Review of the Literature

High-pressure injection injuries (HPII) caused by water swelling sealant are rare at present. The patient generally has small-sized skin lesions, and the misleadingly benign presentation may cause delayed treatment at the early stage of management. In addition, radiographic examination may be underestimated. Subsequently, the inadequate surgical intervention may cause tissue necrosis and poor prognosis. Furthermore, the early recognition of water swelling sealant injected into tissue and emergent surgical intervention are the key to successful management for the patient with HPII caused by injecting water swelling sealant to tissue.

Recent advances in microvascular autologous breast reconstruction after ablative tumor surgery

Breast cancer is a ubiquitous disease and one of the leading causes of death in women in western societies. With overall increasing survival rates, the number of patients who need post-mastectomy reconstruction is on the rise. Especially since its psychological benefits have been broadly recognized, breast reconstruction has become a key component of breast cancer treatment. Evolving from the early beginnings of breast reconstruction with synthetic implants in the 1960s, microsurgical tissue transfer is on the way to become the gold standard for post oncology restoration of the breast. Particularly since the advent of perforator based free flap surgery, free tissue transfer has become as safe option for breast reconstruction with low morbidity. The lower abdominal skin and subcutaneous fat tissue typically offer enough volume to create an aesthetically satisfying breast mound. Nowadays, the most commonly used flap from this donor site is the deep inferior epigastric artery perforator flap. If the lower abdomen is not available as a donor site, the gluteal area and thigh provide a number of flaps suitable for breast reconstruction. If the required breast volume is small, and there is enough tissue available on the upper medial thigh, then a transverse upper gracilis flap may be a practicable method to reconstruct the breast. In case of a higher amount of required volume, a gluteal artery perforator flap is the best choice. However, what is crucial in addition to selecting the best flap option for the individual patient is the timing of the operation. In patients with confirmed post-mastectomy radiation therapy, it is advisable to perform microvascular breast reconstruction only in a delayed fashion.

Four flap suspension technique for prevention of bottoming out after breast reduction

Purpose

Bottoming-out deformity is accepted as the most important disadvantage of inferior pedicle breast reduction. For prevention of this deformity, different techniques are used in combination with inferior pedicle. In this study, we aimed to prevent bottoming-out deformity by producing an internal bra effect through combination of inferior pedicle technique with 2 superior and 2 inferior dermal flaps that were raised from each side of the pedicle.

Methods

Thirteen patients whose medical records became available during the follow-up period at Ankara Training and Research Hospital from January 2010 to January 2015 were included in this study. We retrospectively obtained patient medical records including demographic characteristics and clinical data. Superior dermal flaps were planned on both sides of the pedicle 2 cm inferior to the lower border of areola and inferior dermal flaps were planned 6 cm inferior to the superior dermal flaps. The superior and inferior dermal flaps were secured to the periosteum of the 2nd and 4th ribs respectively with permanent sutures.

Results

Preoperatively, the average distance between the inframammary fold and areola was 13.9 cm (range, 11-18 cm). The average amount of breast parenchymal resection was 745 g (range, 612-1,496 g). The average distance between the inframammary fold and the lower border of the areola was 7.9 cm (range, 7.5-9 cm) on the postoperative first-year measurements.

Conclusion

In conclusion, according to our study, suspension technique to prevent bottoming-out deformity is associated with an easier technique without the need for alloplastic or allogenic materials. Since fixation is performed to the ribs instead of soft tissues like the pectoral fascia or muscle, we believe that this fixation is more long lasting and can be an effective alternative to other suspension techniques.