Ahmet Sönmez

Reliability of primary vein grafts in lower extremity free tissue transfers.

Free flaps transferred to the lower extremity have a higher risk of failure, which may be expected to increase further with the use of vein grafts. The results of 103 consecutive free flaps to the lower extremities of 98 patients who were operated from March 1994 to December 1999 were evaluated to assess the reliability of vein grafts in lower extremity reconstruction. Five flaps were lost and the overall success rate was 95.1%. Eighty-four free tissue transfers in 79 patients were performed for the reconstruction of traumatic cases, and 81 of these flaps were performed in a delayed manner, between 1 week and 4 months after the injury. Interpositional vein grafts were used primarily in 22 flaps—all in traumatic cases—and 21 of them survived completely (95.4%). Primary vein grafts were used both for arteries and veins in 15 flaps and for arteries only in 7 flaps. The most common cause of tissue loss in these patients was a crush injury in earthquake survivors, followed by electrical injuries, gunshot injuries, motor vehicle accidents, and chronic infections. Free muscle flaps in 13 patients, skin flaps in 4 patients, osseous flaps in 2 patients, and temporal fascial flaps in 2 patients were the flaps of choice in vein graft reconstructions. Although a higher incidence of flap loss has been reported with the use of interpositional vein grafts than with regular transfers, and the technical and pathophysiological problems in flap transfers are also high in the lower extremity, the success rate in vein-grafted free flaps did not differ from that of the simple free flap transfers in the current series. This appears to be the result of meticulous preoperative planning and proper selection of recipient vessels during optimal operative conditions.

Reconstruction of the weight-bearing surface of the foot with nonneurosensory free flaps

Neurotized fasciocutaneous flaps and split-skin grafted muscle flaps are the most frequently used free flap alternatives for the reconstruction of weight-bearing surfaces of the foot. An objective comparison of the innate characteristics of these two flap types, with respect to long-term stability, has not been possible because sensory reinnervation in the fasciocutaneous flaps has been a confounding factor. This study compares nonsensate fasciocutaneous flaps (n = 9) with nonsensate split-skin grafted muscle flaps (n = 11), with mean follow-up periods of 34.3 and 31.3 months, respectively. Patients completed a form that included questions regarding degree of pain at the operative site, presence of ulcers, ability to wear normal shoes, employment status, and time spent standing on foot. Touch and deep sensation were evaluated with Semmes-Weinstein and vibration tests, respectively. Significantly less pain and less ulceration (p < 0.05) were observed in the fasciocutaneous group. Semmes-Weinstein monofilament tests revealed poorer results with split-skin grafted muscle flaps, compared with fasciocutaneous flaps. These results indicate that even if the sensory protection of fasciocutaneous flaps is not considered, these flaps have superior properties, compared with split-skin grafted muscle flaps.

Digital blocks with and without adrenalin: a randomised-controlled study of capillary blood parameters.

This study compared fingertip capillary blood gas parameters before and after digital anaesthesia using lidocaine with and without Adrenalin. Twenty patients who underwent surgery on their fingers under digital ring block anaesthesia were randomly anaesthetised with 2% lidocaine or 2% lidocaine with 1:80,000 Adrenalin. Capillary blood parameters were measured prior to the digital blocks and 15 minutes after the injections. In the plain lidocaine group, PO2 and SaO2 increased significantly after injection (P = 0.025 and 0.017, respectively). In the lidocaine with Adrenalin group, PO2 and SaO2 decreased after the injections. However, this decrease was not statistically significant. Patients in the plain lidocaine group had return of sensation to the finger tip 4.8 (±0.6) hours after the operation. This period was 8.1 (±0.8) hours for the lidocaine with Adrenalin group.

Patients' and surgeons' perspectives on the scar components after inferior pedicle breast reduction surgery.

Background: Scarring is the most frequent cause of dissatisfaction both for the surgeons and for the patients in breast reduction surgery. Some of the techniques used today use the classic inverted T scar. An inverted T scar is a combination of three separate scars (periareolar, vertical, and inframammary). To the authors’ knowledge, no study has investigated the cosmetic outcome of these three scar components separately. The aim of this study was to determine the surgeons’ and patients’ perspectives on the cosmetic outcome of these three scar components. Methods: A total of 19 patients who had inferior pedicle reduction mammaplasties were included in the study. The patients’ perspectives on their reduction mammaplasty scars and the surgeons’ evaluations of scar hypertrophy, widening, and color match were assessed by Likert scales. Results: Patient evaluations revealed that periareolar scars were the most pleasing, whereas the inframammary scars were the least pleasing. Surgeon evaluations revealed no significant difference in scar hypertrophy, color match, or widening for the three scar components. However, the vertical scar had a tendency to widen and the inframammary scar color tended to match poorly. Conclusions: In this study, patients were most pleased with the periareolar scars and least pleased with the inframammary scars. Surgeons need to find ways of getting rid of the inframammary scar and should also deal with vertical scar widening. Scar hypertrophy was not a problem in this patient population.

Lipofibromatous hamartoma of the median nerve.

Lipofibromatous hamartoma is a rare tumor-like overgrowth of fibroadipose tissue surrounding the nerves. Most commonly, it involves the median nerve. The tumor is usually present at birth and grows very slowly. The expected age of clinical presentation is the third or fourth decades of life. The case reported here had a rapid overgrowth and presented at the age of eight. Our case is the first reported case of lipofibromatous hamartoma of the median nerve in the pediatric age group.

Analysis of flow changes to the foot after sacrifice of one of the major arteries.

The objective of this study was to find out whether a compensatory increase in blood flow to the foot is observed after sacrifice of one of the tibial arteries. Eleven patients who had one of the tibial arteries as the recipient artery of free tissue transfer to their lower extremities were included. The arterial diameter, cross-sectional area, maximum flow velocity, minimum flow velocity, and flow rate were measured by a Doppler ultrasound in the nonrecipient tibial artery and perforating peroneal artery in the operated limb. The same parameters were measured in the anterior and posterior tibial arteries and the perforating peroneal artery in the contralateral limb. The arterial diameter, cross-sectional area, flow velocity, and flow rate were increased significantly in the nonrecipient tibial artery of the operated limb with respect to the same artery on the contralateral limb. The same changes were not demonstrated in the perforating branch of the peroneal artery. Total blood flow to the foot in the operated extremity was not different from that of the nonoperated foot. The results reveal that if a major feeder to the foot is sacrificed, the other tibial artery compensates for it, and resting blood supply to the foot is not altered.

A neurocutaneous island flap model: an experimental study in rats.

&NA; Neurocutaneous flaps have been popularized recently in clinical reconstructive surgery. However, controversies exist concerning their anatomy and physiology. The particular role of neural vasculature in the survival of these skin flaps is also quite undefined in the experimental setting, and additional studies on this subject are necessary. The goal of this study was to describe a neurocutaneous flap in a rat model and to investigate its blood supply. Thirty male Sprague‐Dawley rats weighing 300 to 350 g were used in this study, which was conducted in two stages. During the first stage, the lower extremities of 10 rats were dissected for the anatomic study of the neurocutaneous flap. A constant cutaneous nerve innervating the anterolateral thigh skin was exposed. It arose either from the saphenous nerve or the superficial epigastric nerve and was accompanied by a constant longitudinal arterial plexus. The tiny neural vessels were conveyed by the superficial fascia along their course. A 30 × 30‐mm cutaneous island flap, which was based only on the cutaneous nerve with its accompanying vessels and a strip of superficial fascia, was raised on the anterolateral thigh skin using an operating microscope. The well‐perfused skin territory was marked after sodium fluorescein injection. The stained skin territory was located centrally and medially on the whole island flap, and it was approximately 10 × 20 mm. This finding was confirmed by the qualitative assessment of the vascularity for this skin territory in microangiography. After studying the pedicle anatomy and determining the optimal viable skin island, the second stage of the study was performed. The remaining 20 rats were divided into two groups. In the experimental group (N = 10), a neurocutaneous island flap (10 × 20 mm) was outlined on the anterolateral aspect of the thigh at its middle third. It was designed in such a way that its short and long axes lay in the center of the distance between the anterior superior iliac spine and the anterior aspect of the knee joint. After identification and dissection of the neurovascular pedicle, the flap was raised in a lateral‐to‐medial direction without including the deep fascia. At this point the flap remained connected only by the pedicle and a strip of superficial fascia surrounding it. It was sutured in the same place. In the control group (N = 10), the pedicle of the flap was severed and the skin island was sutured back as a composite graft. All the experimental flaps survived well. In the control group, none of the flaps survived except one that was partially viable. The flaps in the experimental group were reelevated as neurocutaneous island flaps on day 7 for microangiographic study, and specimens were processed for histologic staining. Microangiography revealed the extent of neural vasculature and vascularization of the skin through cutaneous perforators. Histologic investigation demonstrated the neural vessels that were related closely to the superficial fascia. The authors propose a neurocutaneous island flap model in the lower extremity of the rat in which the survival of the flap depended mainly on the neural arterial supply. It was also demonstrated that the superficial fascia played a role as a connective tissue framework for conveying tiny neural blood vessels to reach the skin. This model may serve as a reproducible and reliable neurocutaneous island flap model for additional studies in this field. Gürünlüoğlu R, Bayramiçli M, Sönmez A, Numanoğlu A. A neurocutaneous island flap model: an experimental study in rats. Ann Plast Surg 2000;44: 53‐58

Use of the one-finger glove for rat anesthesia.

Sir: Various techniques have been described to handle the rat for achieving intraperitoneal injection. If working with an assistant, one method is to grasp the dorsal skin of the rat’s upper back and neck with one hand and base of the tail with other and to invert its ventral surface up with the head lower than its abdomen. This allows the other person to make the injection easily.1 If working alone, one commonly used technique is to grab the tail of the rat at midportion and to lift the animal so that its hind legs are in the air, making the animal rest on the front paws. Then the injection is performed with a syringe in the dominant hand.2 However, this technique seems difficult, especially for the beginner. Although it may be safer when a relatively thick glove is worn to protect against the animal biting, the use of such gloves usually leads to a poor grasp with less control of the rat. For more control, some housing materials such as scrub shirt sleeve or a rat restraining cage can be used.1 But rat restraining cages are not readily available in every laboratory, and the cut-off sleeve of an operating room gown is relatively thin. In our laboratory, we use a thick glove, which is readily available in the market. A thick, one-finger glove is preferred because it is big enough for the rat. The glove is placed on a smooth surface with its opening wide enough for the rat to enter. While holding its tail, one guides the rat into this inviting, dark opening. Care must be taken to avoid irritating the rat. Once the rat is imprisoned in this housing material, its tail is lifted and the injection is given into the abdominal cavity (Fig. 1). The thick glove used in this way also prevents the rat from biting the handler. We believe that the described technique is a practical and safer way of holding the animal with more control for intraperitoneal injection, especially for the beginner working alone. Raffi Gürünlüoğlu, M.D. Ahmet Sönmez, M.D. Teoman Doğan, M.D. Ayhan Numanoğlu, M.D. Department of Plastic and Reconstructive Surgery Marmara University School of Medicine Istanbul, Turkey

Scalp metastases of glioblastoma multiforme: case report

Glioblastoma multiforme is an aggressive neoplasm of the central nervous system and skin metastases are extremely rare. In this article, a patient who had rapidly developing scalp masses after surgery for glioblastoma multiforme is presented. The metastatic masses with ulceration were disturbing for the patient and his family, so he was operated on for palliative resection of the tumor. The resulting extensive defect was reconstructed with a free latissimus dorsi flap. Healing phase was uneventful and he was discharged from the hospital on the ninth postoperative day. A palliative surgery, even if it may necessitate a complex reconstruction, can be recommended in specific cases to improve quality of life and to ease patient care.

Aberrant Perfusion of the Serratus Anterior Muscle Flap: Report of Two Cases and a Review of the Literature

Free serratus anterior muscle flap, classified as Mathes-Nahai type III, is a versatile and frequently preferred choice for soft tissue coverage of small to moderate-sized defects owing to its reliable circulation pattern; however, some anatomic variations in the flap vascularity can result in partial flap loss. Here we present two cases with free serratus anterior muscle transfer where the distalmost portion of the flap was not perfused by the thoracodorsal pedicle. The most likely explanation seems to be the large flap size and the lack of distal interconnections between lateral thoracic artery and thoracodorsal artery branches. Our clinical experience suggests that anatomic variations of serratus anterior muscle circulation might end up with distal perfusion loss if a large flap is to be harvested.