Ahmet Terzioglu

The rate of upper-extremity deep-structure injuries through small penetrating lacerations.

Despite the abundance of epidemiologic studies concerning hand injuries, there is no study that emphasizes the significance of the initial laceration size. The aim of this study is to investigate the incidence of tendon, nerve, and artery injuries that may result from small, penetrating lacerations of the hand and forearm. A total of 226 patients with small lacerations were included in the study. Glass (68.7%) and knife (31.3%) lacerations were the only etiological factors. One hundred thirty-four patients (59.3%) had at least 1 deep-structure injury. One hundred twenty-four patients (92.5%) had at least 1 tendon, 25 patients (18.7%) had at least 1 nerve, and 20 patients (14.9%) had at least 1 artery injury. Extensor tendons were more commonly injured (61.3%). Combination injuries were found in 20 (14.9%) patients. The most-encountered combination was the injury of all 3 structures. Small laceration injuries of the upper extremity have the potential to conceal an underlying deep injury.

Bilateral split latissimus dorsi V-Y flaps for closure of large thoracolumbar meningomyelocele defects.

Closure of large meningomyelocele wounds and defects always requires durable and safe coverage of the dural repair. A new technical method for the reconstruction of large thoracolumbar meningomyelocele defects is described in which bilateral musculocutaneous flaps are advanced and transposed medially in a V-Y sliding manner, based on the thoracolumbar perforatiors of the latissimus dorsi. This procedure provides a reliable, well-vascularized soft tissue coverage over the neural repair with minimum donor-site morbidity. Additionally, this method is particularly appropriate to the thoracolumbar area, as it preserves the lateral adjacent regions of the defect, for later alternative and/or reconstructive options.

The hatchet flap for reconstruction of fingertip amputations.

Background: Emmett has described a single triangular flap that contains a partial skin bridge on one of its sides and called it the hatchet flap. It was successfully used for defects located on various body parts. The aim of this study was to present the authors’ experience and results obtained with this flap in fingertip amputations. Methods: Nine patients who have completed their 1-year follow-up period were included in the study. Two-point discrimination and stiffness were tested, and the patients were queried about the existence of cold intolerance, hypersensitivity, numbness, and pain in the early (3 months) and late (1 year) postoperative periods. Results: The amputations were located on the thumb in three patients, index finger in one patient, middle finger in three patients, and ring finger in two patients. The average defect size was 2.1 × 1.5 cm. Partial wound dehiscence was observed in one patient. The flap has provided good protective padding and aesthetic contour for the fingers. All incisions healed with inconspicuous scars. Average two-point discrimination was 6.3 mm (range, 4 to 8 mm). Cold intolerance was observed in two (22.2 percent) and paresthesia in one patient (11.1 percent). Joint stiffness was not noted. Most patients could return to their normal routine in approximately 4 to 5 weeks. Conclusions: The hatchet flap is a good alternative for transverse and lateral oblique fingertip amputations and valuable for volar oblique amputations (defects <2 cm) with more extensive flap designs. The technique is simple and safe and provides good protective padding and acceptable tactile gnosis.

Periareolar-transareolar-perithelial incision for the surgical treatment of gynecomastia.

Gynecomastia is an abnormal enlargement of the breast tissue in men. It is the most common disorder of the male breast. Surgical sharp resection of the excess breast tissue is still the mainstay of treatment when medical treatment modalities are proved to be ineffective. The authors believe that areolar incisions give the best results, especially for grades I and IIA gynecomastia. The authors review the ever-increasing areolar incision techniques that have been previously recommended, propose a classification for these techniques, and introduce an alternative technique for areolar resection of the enlarged gland in gynecomastia. An inferior pole, periareolar–transareolar–perithelial (PTP) incision was designed and 15 patients were operated successfully using this technique. Twelve cases were bilateral and 3 were unilateral (27 breasts). A 65-mm access port can be obtained from a 30-mm-diameter areola. No color changes or slough was observed in any of the patients. Areolar access incisions can be classified into 4 main groups: circumareolar, periareolar, transareolar, and circumthelial, and their subgroups. Like every incision proposed, the PTP incision cannot be recommended for every grade of gynecomastia. It is best suited for grades I, IIA, and IIB gynecomastia. Its wide exposure and potential advantage for areolar reduction makes this incision a good alternative to other areolar approaches.

A new phenomenon: “sleep lines” on the face

Plastic surgery must achieve the best cosmetic results, and it helps to consider certain skin lines. Aging and scars can cause the face to become lined, and we have noticed various facial lines among patients or their relations who have come to our outpatient clinic. These lines are sometimes single and there are sometimes 2–3 parallel lines generally in the same area of the face, such as the lateral orbital, temporal, frontal, and buccal regions. After detailed evaluation, we concluded that these oblique or horizontal wrinkles were caused by the position in which they slept. All of them slept prone, with their faces buried in the pillow, which over many years has caused wrinkling of the skin. We think therefore that sleeping position should be considered as an aetiological factor in the formation of wrinkles. The lines that should be taken into consideration during operation are Langers lines, or relaxed skin tension lines, but not sleep lines. Here we describe the possible aetiology of sleep lines on the face.

Injuries to children's hands caused by the engine belts of agricultural machines: classification and treatment

Injuries to childrens hands with farm machinery, particularly tractors, are common in rural areas. We present 58 cases of hand injuries in children aged from 3 to 7 (mean 4.5), caused by the engine belts of agricultural vehicles, who were referred from the cities in Central Anatolia. The injury patterns among patients were similar. The injury generally starts from the middle phalanx of the third finger, crosses the proximal phalanx of the fourth finger and ends in the hypothenar region. The patients were categorised into five groups and treatment planned accordingly. The most commonly involved digit was the third finger and the thumb the least. Surgical treatment depended on the severity of the injury and included primary closure of the lacerations, tendon repair, fixation of fractures, grafting, and local flaps. Results of these injuries are generally poor, so prevention is more important.

Consequences of radiation accidents.

Radiation injury attributable to radiotherapy is a topic that has attracted ample attention in the literature, especially in a vast number of publications in plastic surgery. However, the literature is clearly devoid of compilations regarding the effects of ionized radiation accidents. A case of a radiation accident is presented. It is nearly impossible to anticipate the extent of effects of external irradiation of the skin and subcutaneous tissues. The initially healed area should be expected to show late recurrent necrosis. Patients exposed to ionized external irradiation are no longer radioactive and can be treated as ordinary patients. However, these patients should be followed closely for years, keeping in mind the onset of late radiation effects like skin necrosis in various parts of the body, skin and other organ cancers, leukemia, infertility, hypothyroidism, and cataracts.

The prepuce and circumcision: Dual application as a graft

Circumcision is probably one of the first plastic surgery operations that has been used for centuries. The aim of this study was to apply the bilamellar tissue (skin and mucosa) obtained from circumcision to various defects and to evaluate the clinical results. During the last 2 years, 19 patients have been operated, and the skin and mucosal grafts were applied individually or simultaneously. The etiology was trauma for the whole series of patients (12 burns and 7 strap injuries). In 15 patients the defect was localized to the hand whereas in 4 patients it was located on the dorsum of the foot. In 10 patients, mucosa and skin graft were applied to the same defect as a single, compact layer. In 9 patients, skin and mucosa were applied separately to multiple defects. Using these methods, comparative evaluation of the consequences of prepuce mucosal and skin graft applications could be made. Four obvious differences were observed: (1) in mucosal grafts, early graft edema that resolves spontaneously after 48 hours; (2) better adaptation of the mucosal grafts to the recipient bed; (3) hyperpigmentation in both graft types, but the skin part was slightly darker than the mucosa; and (4) less secondary contraction was seen in mucosal grafts. The results were evaluated in light of the authors’ knowledge of the prepuce as an alternative full-thickness donor site. The relative differences in the dual anatomic structure of mucosa and skin, and the role of circumcision as a medical, cultural, and religious application in some societies are discussed.

Romberg's disease associated with Horner's syndrome: contour restoration by a free anterolateral thigh perforator flap and ancillary procedures.

Romberg’s disease (also known as ParryRomberg syndrome or progressive hemifacial atrophy) is a rare pathologic process involving progressive wasting of skin, subcutaneous fat, muscle, and occasionally bones of the face. The condition was first described by Parry in 1825 and later by Romberg in 1846 as “trophoneurisis facialis,” though Eulenberg has coined the term “progressive facial hemiatrophy.” The onset of the disease is slow and progressive and usually commences in the first or second decade of life, more often between the ages of 5 and 15 years.1 It is more common in the female population, with a female-to-male ratio of 1.5 to 1. The atrophy is unilateral in 95 percent of cases. The right and left sides of the face are affected with equal frequency. Pensler et al.,2 in an evaluation of 41 patients, have noted that in all patients the atrophic changes began in a localized area of the face and progressed within the dermatome of one or more branches of the trigeminal nerve. The average age of onset of the disease was 8.8 years, and the mean period of progression was 8.9 6 years. In a group of patients with skeletal involvement in their series, the mean age of onset was 5.4 years versus 15.4 years for patients without skeletal involvement. No correlation could be established between severity of soft-tissue deformity and age of onset. When bony hypoplasia is present, it affects predominantly the middle and lower face.3 The timing of surgery should be based on correction of the deformity after cessation of the ongoing atrophic process, usually after a period of at least 1 year.1 Soft-tissue reconstruction techniques should address the augmentation of deficient soft-tissue volume. There is a wide range of methods described, from dermal fat grafts to free tissue transfers. The myriad of methods reflects the lack of a single best method. The cause of the disorder is unknown, although many theories have been proposed. Among these, the most popular are infection,4 trauma, immunologic abnormality, heredity, trigeminal neuritis, scleroderma, and cervical sympathetic loss.5,6 Regardless of the cause, the resultant deformity is usually characterized by a stable “burned-out” appearance of the hemiface. The proposed theory of alteration in peripheral sympathetic stimulation has gained a certain popularity following studies reporting Romberglike changes observed in laboratory animals after superior cervical sympathectomy.5,7–10 Only one report of Romberg’s disease following thoracoscopic sympathectomy (performed for palmar hyperhidrosis) was reported for humans in the English literature. However, previously, Tebloev and Kalashnikov11 and Tebloev et al.7 reported a total of 28 patients in whom facial hemiatrophy developed after the onset of ganglionitis of the superior cervical sympathetic ganglion, brainstem encephalitis, trigeminal neuralgia, tumors of the gasserian ganglion, and syringobulbia. In contrast, if the sympathetic nervous system is responsible, it remains unclear whether facial atrophy results from postinflammatory hypofunction or sympathetic hyperactivity in the presence of active inflammation.12 Horner’s syndrome (Claude-Bernard-Horner syndrome) is characterized by an interruption of From the Department of Plastic and Reconstructive Surgery, Ankara Education and Research Hospital. Received for publication March 23, 2005; accepted July 28, 2005. Copyright ©2007 by the American Society of Plastic Surgeons

The thenar index: an objective assessment and classification of thenar atrophy based on static hand imprints and clinical implications.

Background: The aims of this study were to test the effectiveness of the subjective clinical evaluation and to search for any possibility of constituting an objective assessment system for the diagnosis of thenar atrophy based on static hand imprints. Methods: Static hand imprints were obtained from normal subjects (group A, n = 116) and carpal tunnel syndrome patients with thenar atrophy (group B, n = 26). Thenar index and the bilateral thenar index ratio were defined. Cutoff values were considered by analyses with receiver operating characteristic curves. Results: No statistically significant difference could be demonstrated in thenar index values of dominant and nondominant hands between genders and age groups (p > 0.05). A statistically significant difference was observed between severity groups in group B (p < 0.05). There was a statistically significant difference between thenar index and bilateral thenar index ratio values of groups A and B (p < 0.05). Cutoff values were considered a thenar index of 31 and a bilateral thenar index ratio of 0.8, which revealed acceptable specificity (95.3 percent) and sensitivity (77.4 percent). A new quantitative classification for thenar atrophy severity is proposed. Conclusions: Understanding the true onset and natural progression of thenar atrophy can only be anticipated with the aid of an objective assessment system. Currently, this method should be regarded as a system for patient records and comparison for presurgical and postsurgical data. The authors believe that the thenar index classification has some merit for future use. It seems that additional objective and scientific evaluation systems and novel approaches are still needed to demystify the true nature of carpal tunnel syndrome.