Standardization of the Rat Dorsal Random Pattern (McFarlane) Flap Model and Evaluation of the Pharmacological Agents Aiming to Salvage Partial Flap Necrosis: A Systematic Review and a Meta-analysis

INTRODUCTION

Partial flap necrosis is a common complication after surgery. McFarlane flap model has been used for assessment of various agents' effects on random flap survival. The aim of this study was to review the methodology of studies using this flap model and reveal the most successful agents.

MATERIALS AND METHODS

PubMed, Scopus, and Web of Science databases were screened for words "McFarlane flap," "flap survival," and ("flap" and "rat") by using time limits between 1965 and 2019. A total of 71 original articles were reviewed. Dimensions and base (cranial/caudal) of the flap, treatment protocol, follow-up period, and survival rates were extracted. Modified survival rates were calculated. Coefficients of variation of cranial/caudally based control group flaps and most commonly used flap models were calculated to assess interstudy variability.

RESULTS

A total of 165 different treatment regimens were studied. One-hundred twelve regimens (67.9%) were found to increase flap survival. Most common flap dimensions were 9 cm × 3 cm, followed by 10 cm × 3 cm, 8 cm × 2 cm and 6 cm × 2 cm. Studies using caudally based flaps showed less interstudy variability, but survival rates were similar. Pentoxifylline, sildenafil, chlorpromazine, phenoxybenzamine, and phentolamine were reported to be successful in multiple studies.

CONCLUSIONS

There are numerous agents found to be effective for treatment of partial flap necrosis, but further clinical research is needed. To overcome standardization problems, use of commonly used flap dimensions with a caudal base and interpretation of results after 7 days of follow-up seems appropriate.

Analysis of 1430 hand fractures and identifying the 'Red Flags' for cases requiring surgery: Head: Hand Fracture Treatment

BACKGROUND

Hand fractures constitute 20% of hand injury patients who apply to emergency services. Conservative approaches are satisfactory in the majority of the cases. However, the minority group in need of surgery reaches a serious number of patients considering the frequency of these injuries. Retrospective questioning of the indications of the performed surgeries is a proper way of understanding the decisional process for surgery.

PATIENTS/METHODS

Patients treated for hand fractures were retrospectively reviewed. Patient gender, age, finger/fingers involved, soft tissue involvement, treatment method (conservative/surgery) and if operated, devices used for fixation were noted. Plain radiographs of the patient were evaluated. Descriptive statistics of these variables and the effect of each variable on the decision for surgery were analyzed.

RESULTS

The study involved 1430 fractures of 1303 patients (1016 male and 287 female). Fifth finger was the most commonly injured digit (31%). Comminuted fractures (29%) followed by transverse fractures (29%) and spiral/oblique fractures (22%) were commonly diagnosed fracture types. Thirteen percent (13%) of the study group needed tendon/nerve/vessel repairs. Male patients, cases with soft tissue involvement, second, third and fourth finger fractures, fractures involving multiple digits, fractures with an intra-articular component, fractures with dislocation more than 4 mm and angulation more than 15° had a significantly higher rate of surgery.

CONCLUSION

Less than half of the hand fractures require surgery, and conservative treatment is usually preferred. Certain variables that indicate surgical treatment were identified with our study. These findings may help to weigh the options and choose the right path in doubtful conditions.

LEVEL OF EVIDENCE

Level 4, Case-control study.

Effect of Platelet-Derived Concentrated Growth Factor on Single-Layer, Multi-Layer, and Crushed Onlay Cartilage Grafts

BACKGROUND

The main concern with utilizing cartilage grafts to achieve structural integrity and volume restoration is the loss of volume over time and their unpredictable viability. Preservation of the volume of cartilage grafts is necessary to ensure their long-term success.

OBJECTIVES

The main aim of this study was to investigate the effect of concentrated growth factor (CGF) sheet on single-layer, multi-layer, and crushed block cartilage grafts.

METHODS

Cartilage grafts obtained from the ears of rabbits were prepared in 3 different forms: single-layer, triple-layer, and crushed. After measuring the weight and thickness of the cartilage grafts, the grafts in the experimental group were wrapped with the prepared autologous CGF. These cartilage grafts were placed in subcutaneous pouches created on the backs of the rabbits. After 4 months, the rabbits were killed. The weight and thickness of the cartilage grafts were measured and the cartilage viability and peripheral changes were examined microscopically.

RESULTS

The percentage changes in the weights and thicknesses of the single-layer, multi-layer, and crushed cartilage grafts wrapped with CGF were found to be statistically significantly lower than in the control group. When the cartilage viability and changes in peripheral tissue were evaluated, CGF-wrapped cartilage groups did not achieve statistically significantly better scores than the untreated control groups.

CONCLUSIONS

In cases planned to receive a block cartilage graft, especially if graft resorption is not desired or should be minimized, wrapping the graft with autologous CGF is a feasible option.

Biomechanical analysis of a modified suture technique for septal extension grafts: Transloop suture

BACKGROUND

A successful rhinoplasty procedure requires a well-defined and properly projected nasal tip; however, surgical control of the nasal tip is difficult. The aim of this investigation was to assess the efficacy and safety of a modified suture technique, which can be used to fix the caudal septal extension graft during primary rhinoplasty of the Asian population and revision septorhinoplasties of the Caucasian population, and to compare it with those of other commonly used techniques.

METHODS

After peeling of perichondrium of scapular cartilages, cartilage pieces of 3 × 1 cm in size and 2 mm in thickness were divided into two from the midline. These pieces were repaired end-to-end using three different repair techniques: two simple interrupted in Group A (n = 40), vertical figure-of-eight in Group B (n = 40) and modified vertical figure-of-eight (transloop) in Group C (n = 40). All repaired cartilage specimens were subjected to a biomechanical analysis, in which four different forces were applied: tension, lateral bending, shearing and buckling.

RESULTS

According to the tensile test, Group C had statistically significantly higher strength than Group A at 2 mm range. The lateral bending test similarly revealed that Group C had statistically significantly higher strength at 1.5 mm and 2 mm range than Group A. However, there was no statistically significant difference between the three groups in the assessment of shearing and buckling forces.

CONCLUSION

The modified transloop suture technique provides a more stable repair, and we consider that it can be used as an alternative suture repair method.

Eight years of clinical experience with digit replantation: Demographic characteristics and outcomes

BACKGROUND

Despite surgical and technical advances in microsurgery, it is still difficult to obtain satisfactory results after replantation of finger amputation. The aim of the present study was to discuss some of the many factors that can affect the success rate of replantation.

METHODS

A retrospective analysis of 60 patients with 85 finger replantations was performed. Revascularizations and replantations proximal to the metacarpophalangeal joint were excluded. Demographic characteristics of the patients, place of injury, mechanism of injury, level of amputation, and success rate were examined.

RESULTS

A total of 53 male and 7 female patients with mean age of 31 years were included in the study. Index finger (27%) was the most commonly replanted digit. Left side was the more affected, with 62%. Mechanism of injury was crush in 56%, guillotine in 23%, and avulsion in 21% of replanted digits. Success rate was 81%, 53%, and 36% in guillotine, crush, and avulsion injuries, respectively.

CONCLUSION

In conclusion, the injury type and personal variables are very important in the rate of replantation success. Knowledge about the effects of different factors on the results of replantation surgery will provide guidance to hand surgeons in order to inform patients and their relatives properly.

Does crossover innervation really affect the clinical outcome? A comparison of outcome between unilateral and bilateral digital nerve repair

Digital nerve injuries are the mostly detected nerve injury in the upper extremity. However, since the clinical phenomenon of crossover innervation at some degree from uninjured digital nerve to the injured side occurs after digital nerve injuries is sustained, one could argue that this concept might even result in the overestimation of the outcome of the digital nerve repair. With this knowledge in mind, this study aimed to present novel, pure, focused and valuable clinical data by comparing the outcomes of bilateral and unilateral digital nerve repair. A retrospective review of 28 fingers with unilateral or bilateral digital nerve repair using end-to-end technique in 19 patients within 2 years was performed. Weber's two-point discrimination, sharp/dull discrimination, warm/cold sensation and Visual Analog Scale scoring were measured at final 12-month follow ups in all patients. There was no significant difference in recovery of sensibility after unilateral and bilateral digital nerve repairs. Though there is crossover innervation microscopically, it is not important in the clinical evaluation period. According to clinical findings from this study, crossover innervations appear to be negligible in the estimation of outcomes of digital neurorrhaphy.

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.

Alternative method for the reconstruction of meningomyelocele defects: V-Y rotation and advancement flap

OBJECT

Skin grafts, skin flaps, fasciocutaneous flaps, muscle flaps, and musculocutaneous flaps have been used for closure of large meningomyelocele (MMC) defects that cannot be closed primarily. The V-Y rotation advancement flap technique has been used successfully for the reconstruction of defects in different areas of the body. In the present study, the authors report on their novel use of this technique in both a binary and a quadruple (butterfly) flap manner for closure of large MMC defects. They also present an algorithm that they developed for the evaluation of MMC defects.

METHODS

Between January 2011 and November 2013, 17 patients (13 girls and 4 boys) with extremely large MMC defects that could not be repaired by direct primary closure underwent reconstruction of the defects with binary and quadruple V-Y rotation and advancement flaps. With the patient prone, the axillary apices, the most craniad point of the intergluteal sulcus, and the posterior axillary lines were marked, and a rectangular area on the back was designed. Edges of the rectangular area and the transverse and longitudinal diameters of the defect were measured and the presence of kyphosis was noted. These measurements and their proportions were used to develop an algorithm for patient assessment. While binary flaps were planned over the transverse diameter of the defects, quadruple flaps were planned over the bisectors of the defects, which were closed by elevating fasciocutaneous flaps.

RESULTS

For patients whose defect diameter to back width ratio was between 0.30 and 0.50 and whose mean ratio of defect area to donor area was between 0.09 and 0.15, binary V-Y rotation and advancement flaps were used. When these values were in the range of 0.50-0.66 and 0.16-0.35, respectively, quadruple V-Y rotation and advancement flaps were preferred. The mean duration of postoperative follow-up was 10.4 months. With the exception of minor complications, such as partial necrosis of 0.5 × 0.5 cm in a quadruple flap, all the flaps healed uneventfully.

CONCLUSIONS

With this study, closure of MMC defects with V-Y rotation and advancement flaps has been defined for the first time in the literature. The use of this technique with multiple flaps is an effective alternative to other flap options for the closure of large MMC defects. The algorithm developed in the course of this study should facilitate evaluation and reconstruction planning for patients with MMC defects.

Effect of topically applied sildenafil citrate on wound healing: experimental study

Wound healing is a complex process that necessitates organization of different cell types and several signalling molecules. The aim of this study is to evaluate the effect of different concentrations of sildenafil citrate, which decreases cGMP degradation, on wound healing by secondary intention.This study was performed using 25 Sprague Dawley rats weighing 200-250 grams. 4 dorsal defects were created. Four different treatment modalities which were 1% and 5% sildenafil citrate gel prepared with carbopol, pure carbopol gel without any drug in it and 0,9% NaCl solution; were applied to each lesion of the same rat. Randomly selected five rats (25 rats in total) were sacrificed on 3rd, 5th, 7th, 10th, and 14th days; and the effect of each modality was evaluated by means of defect area measurement, histopathological examination and measurement of tissue hydroxyproline levels.Sildenafil citrate gel application decreased the defect areas in a dose independent manner starting from 3rd day and dose dependent manner after 7th day. By means of vascularization, sildenafil citrate increased vascularity starting from 3rd day. The strength of acute inflammation was superior in sildenafil groups starting from 5th day; and the amount and maturation of granulation in the wound bed, as well as the strength of chronic inflammation were superior in defects treated with sildenafil citrate as early as 7th day.

Prevention of tendon adhesions by the reconstruction of the tendon sheath with solvent dehydrated bovine pericard: An experimental study

BACKGROUND

The achievement of the kinetic functions of a finger in full range of motion after the injury and the repair of the flexor tendon has been a challenging issue in hand surgery. Several current studies emphasize the importance of the tendon sheath for the healing of the tendon and for the prevention of the adhesive bands and advise primary repair or reconstruction of them. Various biological and synthetic materials have been used for this purpose with different rates of success.

METHODS

In this experimental study, the sheaths of flexor tendons of chicken toe were excised and three groups were observed: group 1, primary sheath not repaired; group 2, sheath repair with autogenous fascia; and group 3, sheath reconstruction with solvent dehydrated bovine pericardium (SDBP).

RESULTS

Histopathologic evaluations were performed on the 3rd and 12th weeks to determine the outcome of the repair methods regarding the gliding surfaces of the tendons, adhesion rates, and inflammatory reactions, which are the main issues on the healing of the tendon. The results indicated less formation of adhesions in group 3 compared with groups 1 and 2 (p = 0.001).

CONCLUSION

The results showed that SDBP can be used for the reconstruction of the sheaths successively for the prevention of the adhesive bands in flexor tendon surgery.

An Alternative Technique for Microsurgically Unreplantable Fingertip Amputations

Reattachment of the amputated fingertips as composite grafts has been performed for distal levels in children, with high rates of good outcome, but the majority of the reports emphasized that this procedure had success rates only up to 50% in adults. Several techniques to enhance composite graft take in adults have been defined. In this study, a technique to enhance nonmicrosurgical replantation of amputated fingertips as composite grafts is presented.Twenty-three patients were treated with this technique, 20 of which were adults. An area of skin on the amputation margin of the stump was deepithelized, and the amputated part was defatted to reattach the piece as a cap composite graft and to increase the contact area. The patients were evaluated after the operations regarding functional and esthetic outcome. Success rates of 86.95% in total and 85% in adults were achieved, with acceptable sensibility (with a mean value of 7.26 mm for the 2-point discrimination), minimal shortening (a mean value of 6.80 mm), and satisfactory esthetic outcome using this technique.

Evaluation and Management of Exposed High-density Porous Polyethylene Implants

Numerous autogenous and alloplastic materials have been used for restoration of contour deformities of the face. Alloplastic materials have come into use to replace autogeneous bone grafts because bone grafts are associated with donor site morbidity, resorption and difficulty in shaping. Porous high-density polyethylene (HDPPE) is a commercial product which is nonallergenic, nonantigenic, noncarcinogenic and nonresorbable, highly stable and somewhat flexible. It has pores of 125-250 mum which enable tissue ingrowth resulting in firm attachment and integration of the implant to the surrounding tissues. In this study we aimed to evaluate the fate of the exposed implants and proposed a method to manage the exposed medpor implants. Twenty rats were used for this experimental study. Three phases involving the implantation, exposition, and the closure of the implants were held respectively. Closure was performed in two groups: 1) After perforating the exposed implants; 2) Without perforating the exposed implants. No serious complications were seen. Perforated exposed implants when covered with flaps rather than grafts could be covered. Exposed implants were not covered easily as indicated by the previous studies. This study demonstrates that early closure of perforated implants with flaps can give the best clinical results when exposed implants are covered in a short period after exposition so that the ingrown fibrous tissues are still intact. We believe that grafting of the exposed medpor implants cannot be effective either in early or late period. Perforating the exposed implants yield successful results as ingrowth of the tissues are enabled.

Combined use of hair and fibrin glue for soft tissue augmentation: experimental study

A vast variety of alloplastic materials together with autogenous grafts have been used for the correction of contour deformities related to aesthetic and reconstructive purposes. Despite a number of well-tolerated materials, the ideal has not yet been reached, although well-tolerated autogenous grafts have higher rates of resorption and distortion. The limited volume of autogenous grafts and concerns about donor-site morbidity may obligate the surgeon to use implantation materials. Covering almost every property of an ideal implantation material, hair, an organic autogenous nonvital tissue, was used for soft tissue augmentation in this experimental study. Hair pellets of 10 New Zealand rabbits were prepared and shaped as 1 x 1 x 1-cm cubes with the help of fibrin sealant, then inserted subcutaneously. The materials were evaluated 4 months later. No complications such as infection or extrusion were seen. The materials were intact, with no signs of resorption, but the shapes were distorted due to the pressure of the surrounding tissues. Histopathologic findings also demonstrated that the hair was well tolerated by the adjacent tissues. Different processes may enable hair to be used as a filler material in clinical practice. Well-tolerated, nonresorbable injectable materials or shaped implants may be obtained at low cost using hair.

Basal cell carcinoma in Turkey

Basal cell carcinoma (BCC) is the most common form of cancer in Caucasians. This study was undertaken to define clinical features of BCC treated by surgical excision in Turkish patients. One-hundred and ninety-eight patients with 216 BCC, all treated by surgical excision, were studied prospectively. Age and sex distribution, personal and family history, skin type, site and size of the lesions, clinical type of the lesions, status of surgical margins and incidence of recurrence were analyzed. The male to female ratio was 9:10, and the average age of the patients was 64.5 years. Of the tumors, 91.5% occurred on the head and neck. There was also personal and/or family history of cancer in 24.8% of our cases. Of all BCC treated, 83.8% had a noduloulcerative clinical appearance. The vast majority of our patients were Fitzpatrick type 3 (53.0%) and type 2 (41.5%). There were seven recurrences after follow-up periods varying between 3 months and 2 years. In conclusion, clinical characteristics of BCC in Turkish patients have both similarities and differences compared with other countries.

Rhinoplasty model in rabbit

BACKGROUND

Rhinoplasty has become one of the most frequently requested and performed surgical procedures for both functional and aesthetic purposes. As an attention-attracting prominence, even the slightest disfigurement of the nose causes serious disturbance to the patient before or after the operation. Functional problems also cause discomfort. For these reasons, postrhinoplasty complications are regarded as challenging problems for both for the patient and the surgeon. Some cases necessitate grafts for better aesthetic or functional outcome, but there is still controversy over the preference for autogenous or allogenous grafts, both for primary and secondary cases. Evaluation of autogenous and allogenous grafts implanted in the nose is quite challenging for several reasons, including the possibility of unpredictable complications leading to catastrophic disfigurements, the impossibility of obtaining pathologic specimens, and the need for a long follow-up period for stable results. An experimental model for rhinoplasty, fulfilling the need for precise evaluation, was planned and performed after anatomical observation of the noses of rabbits.

METHODS

Fifteen adult New Zealand rabbits were used, five for the anatomical evaluation and 10 for the rhinoplasty model. Computed tomographic images and measurements were obtained before and after the surgical processes.

RESULTS AND CONCLUSION

This experimental model for rhinoplasty has not been reported in any previous studies. This study demonstrates the surgical anatomy of the rabbit in detail and constitutes a guide for researchers as a convenient experimental model for rhinoplasty, with all stages similar to those performed on humans.

Perforating Arteries of the Gluteal Region

Gluteal artery perforator flaps have gained popularity due to reliability, preservation of the muscle, versatility in flap design without restricting other flap options, and low donor-site morbidity. Today, free or local flaps based on the perforating arteries of the gluteal region are among the most commonly used procedures for the management of lumbosacral defects and autologous breast reconstruction. An anatomic study was carried out to investigate localization, dimension, and distribution of the perforator arteries in 16 gluteal regions of 8 formol-fixed cadavers. The total number of perforators in each gluteal region was 13-20 (mean 17 arteries). Mean vessel diameter and mean vessel length were 1.1 mm (range 0.7-1.7 mm) and 6.4 cm (range, 5.2-9.1), respectively. Topographic analysis of the perforators revealed that the gluteal region can be divided into 3 parts in terms of vessel density. The majority of the perforators were localized in superior zone, whereas the middle zone was documented to be the poorest region. Data derived from this analysis were also confirmed by individual analysis of each cadaver.

Basal cell carcinoma in Turkey

Basal cell carcinoma (BCC) is the most common form of cancer in Caucasians. This study was undertaken to define the clinical features of BCC treated by surgical excision in Turkish patients. A group of 198 patients with 216 BCCs, all treated by surgical excision, were studied prospectively. The age and sex distribution, personal and family histories of the patients, skin type, sites and sizes of the lesions, clinical types of the lesions, status of the surgical margins, and incidences of recurrence were analyzed. The male to female ratio was 0.9, and the average age of the patients was 64.5 years. Of the tumors, 91.5% occurred on the head and neck. There were also personal and/or family histories of cancer in 24.8% of our cases. Of all BCCs treated, 83.8% had a noduloulcerative clinical appearance. The vast majority of our patients were Fitzpatrick type 3 (53.0%) and type 2 (41.5%). There were seven recurrences after follow-up periods varying between three months and two years. In conclusion, the clinical characteristics of BCC in Turkish patients have both similarities and differences compared to those of other countries.

Kirschner-Wire Fixation for Postburn Flexion Contracture Deformity and Consequences on Articular Surface

Kirschner-wire (K-wire) fixation for 3-6 weeks is an approved method for stabilization of the fingers after the release of flexion contracture deformity. On the other hand, articular surface damage in small joints due to pin fixation is still a topic of debate. Reports claiming permanent joint destruction due to this procedure exist in the literature. To clarify this doubt, a prospective study was carried out in 72 patients with flexion contracture of the hand fingers. After the surgical release of the deformity, immobilization of the interphalangeal (IP) and metacarpophalangeal (MCP) joints was carried out with K-wire fixation for 3 weeks. Clinical evaluation of the patients was accomplished with total active motion (TAM), grip, and pinch force measurements, whereas magnetic resonance (MR) and radionuclide imaging were used as radiodiagnostic tools. Mean follow-up period of the patients was 32 months. Satisfactory results were obtained in terms of functional and esthetic aspects. Evaluation of the data derived from the clinical and radiologic measurements revealed no permanent articular surface damage. K-wire fixation was documented to be an invaluable therapeutic approach not only to prevent recurrence of the contracture deformity but also to stabilize the skin graft effectively. This technique was concluded to provide effective immobilization without permanent articular damage.

Lower Eyelid Orbicularis Oculi Musculocutaneous Flap for Reconstruction of Nasal Tip and Supratip Defects

BACKGROUND

In clinical practice, there are many ways to reconstruct nasal defects. Despite this fact, achieving a desirable image and better functional results is still a problem. Banner, bilobed, and dorsal nasal flaps have recently been used to reconstruct defects up to 2 cm. For defects larger than 2 cm, flaps raised from the frontal region and face are used. The major disadvantages of these flaps are the visible scar and the frequent need for a second session.

METHODS

The authors used orbicularis oculi musculocutaneous flaps raised from the lower eyelid, containing branches of the angular artery and the infraorbital artery in its pedicle, to reconstruct nasal tip and supratip defects. Between February of 2002 and March of 2004, reconstruction with orbicularis oculi musculocutaneous island flaps raised from the lower eyelid was performed on 15 patients (eight men and seven women) with nasal tip and supratip defects. Thirteen defects were secondary to basal cell carcinoma and two were secondary to congenital melanocytic nevus. The diameter of the defects ranged between 2.1 and 3.1 cm (average diameter, 2.5 cm). Patients were between 25 and 72 years old (average age, 52 years).

RESULTS

Patients were followed up for an average period of 6 months (range, 1 to 12 months). In two patients (13.3 percent), postoperative venous problems were seen but resolved in 3 days. Partial necrosis developed in one patient (6.6 percent). In one patient (6.6 percent), minimal scleral show was seen in tolerable ranges. Neither ectropion nor other eyelid deformities were seen.

CONCLUSIONS

The authors believe that this flap is a good alternative for reconstruction of nasal defects because of its advantages, namely, the need for only a single session, minimal donor-site morbidity, better color and thickness match, and easy and faster surgery.

Improved Flap Viability With Site-Specific Delivery of Sildenafil Citrate Using Fibrin Glue

Sildenafil is a cyclic guanosine-specific phosphodiesterase type 5 (PD-5) inhibitor that is widely used for erectile dysfunction. Potent and competitive inhibition of PD-5 enhances levels of cyclic guanosine monophosphate (cGMP). Fibrin glue-apart from tissue fixation-has been used for slow release of drugs. In this study, local delivery of Sildenafil citrate with fibrin glue was accomplished to improve random flap survival. Fifty Wistar rats were randomized into 5 groups, and a standardized dorsal random-pattern skin flap was elevated in each rat. In Group I (n = 10), the base of the flap was divided, making it a "graft" control to study the graft effect. In Group II (n = 10), a thin Silastic sheet was used to separate the flap from the underlying vascular bed, and no pharmacologic treatment was given. In Group III (n = 10), only 0.5 mL of fibrin glue was applied to the flap donor site. In Group IV (n = 10), 2.5 mg of sildenafil citrate mixed in 0.5 mL of fibrin glue was applied to donor site of the flap, whereas 10 mg of sildenafil citrate mixed in 0.5 mL of fibrin glue was applied in Group V (n = 10). Area of flap survival was evaluated on postoperative seventh day. Total necrosis of all of the flaps was observed in "graft" control group (Group I). Sildenafil and fibrin glue groups (Group IV and V) resulted in a statistically significant decrease in flap necrosis compared with Groups II and III (P < 0.0001). A statistically significant difference could not be documented between Group II and Group III (P > 0.0001). The decrease in skin necrosis was statistically significant in Group V compared with Group IV (P < 0.0001). Histologic examination revealed significantly increased vascular density in Groups IV and V compared with Groups II and III (P < 0.0001), whereas a significant difference could not be documented between Groups IV and V (P > 0.0001) and between Groups II and III (P > 0.0001). In view of these results, topical sildenafil application seems to improve flap survival in random-pattern skin flaps in dose-dependent manner.

Osteogenic Capacities of Periost Grafts, Periost Flaps and Prefabricated Periosteal Flaps: Experimental Study

Reconstruction of the bone defects due to various causes is still one of the challenging problems in plastic and reconstructive surgery. Periosteum is accepted to be the essential source for the repair of the bone tissue, which constitutes the basis of the support and the mobility functions of the surrounding tissues. Periosteal grafts and flaps have been used for various purposes by numerous techniques. The osteogenic activity of the periosteal tissues has a great importance regarding the purposes of reconstruction. In this experimental study, 20 New Zealand rabbits were used for the evaluation and the comparison of the osteogenic activities of periosteal grafts, periosteal flaps and prefabricated periosteal flaps. Morphological, histopathological and scinthigraphical observations were carried out for the assessment and the comparison of the groups after a follow-up of 12 weeks. Two of the animals were left out as a result of infection. The results showed that periosteal flaps had a much faster and more stable reconstructive capacity of osteogenesis, whereas prefabricated periosteal flaps had an osteogenic capacity of a lower degree and periosteal grafts apparently less than the former groups. We believe that this study confirms the reconstructive capacity of prefabricated periosteal flaps as an alternative to periosteal flaps for the repair of osseous tissues as well as indicating the osteogenic capacity of the periosteal grafts, though in a lesser degree.

Neuromuscular Hamartoma of the Occipital Nerve: Clinical Report

Neuromuscular hamartoma is a rare benign tumor consisted of well-differentiated striated muscle fibers within mature neural elements. Though most cases are composed of solitary masses associated with major peripheral nerves, multiple tumors or subcutaneous tumors without any association with peripheral nerves have also been reported. Twenty-three neuromuscular hamartomas of various anatomical locations have been reported in English literature. There have been no reports of this tumor in association with the occipital nerve. An interesting case of neuromuscular hamartoma of the occipital nerve is presented and previous reports about this rare pathology is reviewed.

Closure of Meningomyelocele Defects With Bilateral Modified V-Y Advancement Flaps

BACKGROUND

Although several different methods were described in the literature, closure of large meningomyelocele defects presents a challenging problem. Wound dehiscence may lead to devastating complications. In this paper, the efficacy of the bilateral modified V-Y advancement flap procedure was investigated in terms of simplicity, donor-site morbidity, and reliability.

PATIENTS AND METHODS

The authors presented 10 neonates treated with a modified subcutaneous advancement procedure. Unlike the typical V-Y advancement techniques, the apical extensions of the "V" flaps were elevated based on the paraspinous perforators. A standard closure algorithm was not followed, as the well-vascularized apical extensions facilitated intraoperative decision making for the most appropriate adaptation pattern, depending on the size, shape, and localization of the defect. As well as that, transposition of these apical flaps to the defect site was further supported by the advancement of the V-Y flaps to decrease the tension along the closure.

RESULTS

Mean follow-up period was 13.6 months (range 3-37 months), and no complications that might be attributable to the operative procedure were observed.

CONCLUSIONS

Utilization of bilateral modified V-Y flaps for the closure of large meningomyelocele defects is a simple and effective procedure. Main advantages of the method described in this paper may be listed as follows: simplicity, reliability due to coverage of the defect with well-vascularized flaps, minimal bleeding, decreased operative time, and no donor-site morbidity.

A new anatomical repair method for the treatment of ingrown nail: prospective comparison of wedge resection of the matrix and partial matricectomy followed by lateral fold advancement flap

Currently, there are various surgical treatment modalities for ingrowing nail. None of these procedures are perfect to achieve esthetic results with low cost, recurrence, and complication rates. Eighty-seven toenails of 77 patients were operated in our clinic; 49 wedge matrix resections (WMR) and 38 partial matricectomy followed by lateral fold advancement flap (LFAF) were applied. Average follow-up period of the patients was 13 months. The recurrence rates, spicule formation, immobilization periods, and patient satisfaction for cosmetic result and discomforting symptoms were investigated. Nail, distal phalanx bone, soft tissue measurements were performed in the counterlateral healthy toe of 34 patients that we operated due to the unilateral ingrowing nail and 34 randomized individuals with no ingrowing nail by lateral and anteroposterior toe x-rays. There were no significant differences for age, sex, the side of the ingrowing nail, postoperative mobilization period, and the follow-up period between 2 groups that the techniques were applied to. There was no statistically significant difference in WMR (8.1%, 4 toes) and LFAF (none) for the recurrence rate. But there was significant difference between WMR (36.7%, 18 toes) and LFAF (5.2%, 2 toes) for the spicule formation rates (P < 0.05), and there was significant difference between WMR (20.4%, 10 toes) and LFAF (none) for the reoperation (P < 0.03). It was observed that patient satisfaction in cosmetic view was better in patient group treated with LFAF (P < 0.05). Phalanx heads were wider in patient group with ingrowing nail at the results of the measurements (P < 0.01). The fact that granulation and scarred tissues are removed instead of performing the great soft tissue excisions is more correct for both recurrence and cosmetics. Partial matricectomy and LFAF is a good alternative method for the treatment of ingrown nail, with less recurrence rates and cost and better cosmetic results.

Solvent Dehydrated Costal Cartilage: Evaluation in a Rabbit Model

An experimental study has been performed on 30 New Zealand rabbits to compare autogenous cartilage harvested from the rabbits' auricles, bone graft harvested from the iliac crest of the rabbits, and the commercially available solvent dehydrated human costal cartilage (SDHCC) grafts, each measuring 1 x 1 cm. The grafts are divided into two groups, one group of grafts are inserted into pouches on the cranial bones subperiosteally and the other subfascially on the back of the animals. The grafts are evaluated on the 4th and the 12th weeks. No problems, such as dehiscence, hematoma, infection, erythema, flap necrosis, or graft exposition, occurred during the postoperative follow-up. SDHCC grafts are well tolerated and preserved by the host. They are infiltrated by the fibrous connective tissue and are firmly fixed to the surrounding structures. By the end of 12th week, the thickness of SDHCC grafts were not significantly different, compared with autogenous cartilage grafts, but both were thicker than the autogenous bone grafts. Viable chondrocytes and active cartilage development on SDHCC grafts were seen by the 4th week and chondrogenetic and osteogenetic activity on the 12th demonstrate the feasibility of clinical use of SDHCC grafts for soft and bony defects.

An unusual chondroid syringoma

A case report of a clinically malignant mass measuring 10 x 8 x 10 cm over the shoulder of a 55-year male patient is presented. In the ultrasound examination, it was indicated that the soft tissue tumor did not invade the chest wall. The excisional biopsy revealed a benign chondroid syringoma. This is a report of a quite rare chondroid syringoma case and its clinical presentation, localization, and diameter.

Total lower lip reconstruction using sensate composite radial forearm flap

In modern plastic and reconstructive surgery, shape and function must be considered together. These are the most important goals of any operation. There are a lot of techniques that have been reported for total lower lip reconstruction. It is believed that the radial forearm flap is the most suitable technique for lower lip and chin reconstruction after tumor excision so as to achieve better shape and functional results. The sensate radial forearm-palmaris longus free flap was used for total lower lip reconstruction in 17 patients with lower lip carcinoma with a mean age of 51 years. Two of the patients were female, and 15 were male. All the patients had squamous cell carcinoma. The patients were followed up for 1 to 3 years. Complications of these operations were partial superficial flap loss in 1 patient, partial graft loss in the donor areas of two flaps, and infection in only 1 patient. Wound dehiscence, fistula formation, suture abscesses, or sialocele was not seen in any patient. In this study, the aim was to demonstrate that the sensate radial forearm flap could produce acceptable esthetic results, good sphincteric function, and sensation in the early period after surgery.

Polydactyly: a study of four generations of a Turkish family including an affected member with bilateral cleft lip and palate

Polydactyly is one of the most common congenital deformities of the hands. It can occur as an isolated disorder, in association with other malformations of the hands or feet, or as part of a syndrome. It can occur sporadically but it can also be inherited with a mainly autosomal dominant inheritance. We present a Turkish family with affected members in four generations. Bilateral duplication of the second digit in both hands and feet with 24 digits in total was the most common pattern, but one affected member had 26 digits: seven on each hand and six on each foot. In addition, another affected member had complete bilateral cleft lip and complete cleft palate combined with bilateral hand and foot polydactyly without any syndromic association. The pedigree of the affected members of this family suggests an autosomal dominant mode of inheritance, but genetic expression is variable.

Skin and soft tissue necrosis following hymenoptera sting

BACKGROUND

All kinds of bees, wasps, and hornets are members of the hymenoptera order. Local hypersensitivity reactions after bee stings are very common and well studied. However, tissue necroses following untreated bee stings are extremely rare and they are not well documented.

OBJECTIVE

Two extremely rare cases of extensive skin and soft tissue necrosis following hymenoptera stings are presented. Current literature and treatment options are discussed.

CONCLUSIONS

Local skin reactions following bee stings may result in severe complications such as tissue necrosis if left untreated. Skin grafting following surgical debridement is an adequate and practical treatment modality for such cases.

Late-onset superficial lymphatic malformation: report of a case and review of the literature

BACKGROUND

Superficial lymphatic malformations are predominantly developmental malformations of infancy, but they may arise at any age.

OBJECTIVE

To describe a patient with a late-onset superficial lymphatic malformation.

METHODS

Case report and literature review.

RESULTS

A 53-year-old woman was evaluated for a colored lesion that developed spontaneously on the anterior abdominal wall. The lesion was treated by surgical excision. Findings on histopathologic examination of the specimen were consistent with superficial lymphatic malformation. There was no recurrence of the lesion at 4 months after the operation.

CONCLUSION

Superficial lymphatic malformations can develop in adults spontaneously without the presence of any predisposing condition. Because the majority of such late-onset malformations reported in the literature are localized lesions similar to the one in our patient, surgical removal with inclusion of subcutaneous tissue usually results in cure without recurrence.

Giant dentigerous cyst occupying the right hemimandible

Dentigerous cysts are the second most common odontogenic cysts of the mandible. They may vary in size from 2 cm to more than 10 cm. In the present report, a dentigerous cyst with massive involvement of the right half of the mandible in a young patient is presented. For cosmetic reasons and long term risks these cysts must be treated. Surgical removal is the preferred modality and a submandibular route should be chosen in large lesions. Bony cavities may be decreased in volume by using osteoperiosteal flaps, but there is no need for primary bone grafting, even for large defects.

Report of two cases with Van der Woude syndrome: a child and her mother

Report of two cases with Van der Woude syndrome: a child and her mother: Congenital pits of the lower lip are rare malformations. They are closely associated with cleft lip (CL), cleft lip/palate (CL/CP) or isolated cleft palate (CP) and if so this condition is known as Van der Woude syndrome, which is inherited in an autosomal dominant fashion with high penetrance. Two individuals, one with lower lip pits and cleft palate and the other with isolated lower lip pit from the same family are described. Autosomal dominant pattern of inheritance was observed in this family and treatment consisted of complete removal of sinus tracts in one patient. Pathological features of sinus tracts consisted of stratified nonkeratinized squamous epithelium and a lamina propria of dense connective tissue. Importance of genetic counseling is emphasized as at least half of gene carriers have some kind of clefting.

Reconstruction of mandible with fibula free flap

The fibula can be used as a donor for a free flap for mandible reconstruction. It has the advantages of low donor site morbidity, consistent shape, ample length, and distant location to enable a two-team approach, allowing multiple osteotomies because of its periosteal circulation. It can be raised with a skin island for composite tissue reconstruction. Eight segmental mandibular defects (average 11.62 cm) were reconstructed following resection for tumour. Six defects consisted of bone alone and the other two had only a small amount of associated intraoral soft-tissue loss. Two patients underwent primary reconstruction. We performed two or three osteotomies on each graft and used miniplates and wires for bone fixation. The flaps survived in all patients. All osteotomy sites healed primarily. The aesthetic result of reconstruction was satisfactory.

Dorsal adipofascial turn-over flap for fingertip amputations

We designed a dorsal adipofascial pedicled flap to cover amputations of the tip of the same digit. This flap includes all the adipofascial tissues from the dermis to the paratenon of the extensor tendons. After elevation of the skin, the adipofascial tissues are raised as a flap and turned over to resurface the exposed bone or joint and then covered with a split thickness skin graft. Ten digital amputations between the distal phalanx proximal to the nail matrix and the mid portion of the middle phalanx were successfully resurfaced with dorsal adipofascial turn-over flaps. All flaps survived completely and the mean follow-up was 11 months. This one-step procedure would seem to be a relatively simple way of achieving early recovery because it does not require the use of distant flaps immobilization of adjacent digits, or homodigital flaps that might jeopardize an already injured finger.

A new approach for the treatment of recurrent large abdominal hernias: the overlap flap

In this article we report a new technique for the treatment of recurrent large abdominal hernias and skin laxity: the overlap flap. This technique combines abdominoplasty with hernia repair. Obese patients with recurrent large abdominal hernias and skin laxity could benefit from this operation. This operation could not be performed in patients with a wide absence of the abdominal wall. A total of six patients were treated with this technique in our clinic. Follow-up of the patients has ranged from 1 to 4 years. Cosmetic results were excellent in all patients. No recurrence of the hernias has been observed in any of the patients. Two flaps are prepared; the lower one is deepithelialized, and it is used as an autogenous mesh in place of a prosthetic material to reinforce the abdominal wall, and the upper flap is prepared and overlapped on this lower one.

A new technique for distal hypospadias repair: advancement of a distally deepithelialized urethrocutaneous flap

We report on a new modification technique and the latest results of a procedure for treating cases of distal hypospadias with minimal or no chordee called advancement of a distally deepithelialized urethrocutaneous flap. This procedure incorporates correction of chordee, mobilization of the urethrocutaneous flap, and advancement of the flap through a tunnel until it reaches the tip of the glans. A total of 30 children underwent treatment using this procedure in our clinic. Follow-up of the patients ranged from 2 months to 3 years. Cosmetic results were excellent in all the patients. Fistula formation has been observed in only one patient, possibly due to a surgical accident. This technique may only be applied in distal hypospadias patients with minimal or no chordee in whom the meatus is localized to the coronal level or 0.5 cm proximal to it. Patients with a short urethra or in whom the meatus is distally localized but with severe chordee are not candidates for this technique. In general, this technique is not applicable in patients with ventral penile curvature. We would like to emphasize that this repair technique allows for simple and safe dissection of the distal urethra composed of only mucosa without corpus spongiosum around it. This kind of distal urethra can be advanced easily to the tip of the glans penis with the help of the dermal component.