Ali Barutçu

The distally based superficial sural artery island flap: clinical experiences and modifications.

&NA; The coverage of defects of the Achilles tendon, malleoli, and heel remains a challenge to reconstructive surgeons. The distally based superficial sural artery island flap is vascularized by the median superficial sural artery, posterolateral septal perforators originating from the peroneal artery, neurovascular arteries of the sural nerve, and combinations of these systems as suprafascial plexus. We used distally based superficial sural artery island flaps for the reconstruction of defects of ankle, malleolus, and heel in 17 patients between 1991 and 1997. The largest flap we have used until today was 12 cm in width and 15 cm in length. All flaps have survived. However, we observed venous congestion and edema in two flaps. Also, marginal necrosis occurred in two flaps for which we had not taken the sural nerve with the flap. After these complications, we made some modifications. We left a skin extension over the fasciovascular pedicle and used it as a roof of the tunnel. We took the sural nerve and the deep fascia in all cases. The main advantage of this flap is a constant and reliable blood supply without sacrifice of a major artery. In addition, this is a one‐stage, safe and easy procedure that can be used for large defects. (Plast. Reconstr. Surg. 102: 2358, 1998.)

Submental artery island flap for reconstruction of the lower and mid face.

Ideal reconstruction of facial defects should be accomplished by like tissue. The submental artery island flap has the same characteristics as facial tissue, consisting of thin, pliable tissue with a perfect color match. The flap can be manipulated in different configurations employing skin, the platysma, the rim of the mandible, and the anterior belly of the digastric muscle to be utilized in the reconstruction of complex defects. The pedicle of the flap is quite reliable and enables a wide range of applicability. We have used this versatile flap successfully for various defects in 14 patients and our results are presented. Ten of the 14 flaps consisted of the skin and platysma, two flaps also included the anterior belly of the digastric muscle, one flap was elevated with the rim of the mandible, and one flap consisted of skin, the platysma, bone, and muscle.

Craniofacial reconstruction with high-density porous polyethylene implants.

Deformities of the facial skeleton may be reconstructed using autogenic or allogenic materials. Porous polyethylene is one of the few alloplastic materials currently in use having a well-documented history of reconstruction or augmentation in the maxillofacial region. High-density porous polyethylene, which is shown to be effective as a biomaterial, has additional advantages like tissue ingrowth, no capsule formation around it, and easy fixation. In this study, 83 implants in 71 patients were evaluated. Seven patients were in need of a second intervention. Three of the seven secondary interventions were for contour alignment, and four interventions were for extraction of the implants because of extrusion or infection. Placement of porous polyethylene implants directly under the skin without coverage of periosteum or another fascial envelope has an increased risk of early and especially late exposure. In cases like nasal dorsum or microtia reconstruction, we prefer autogenic grafts instead of allogenic materials.

Prevention of peritendinous adhesions following flexor tendon injury with seprafilm.

Peritendinous adhesions are the most important complication of flexor tendon injury. In this study, Seprafilm was used for the prevention of peritendinous adhesions following flexor tendon repair. Seprafilm Bioresorbable Membrane (Genzyme Corporation, Cambridge, MA) contains sodium hyaluronate and carboxymethyl cellulose. Thirty New Zealand white male rabbits were divided equally into 3 groups. In all groups, the deep flexor tendon of the third finger of the left back foot was cut and repaired by Kessler-Tajima suture technique. In the first study group following tendon repair, Seprafilm was wrapped around the repaired tendon. In the second study group, sodium hyaluronate gel was injected to the operation field after tendon repair. In the control group, no external material was applied to the field. The study groups had better range of motion. Histopathologically, study groups had less adhesions compared with the control groups. As a result, it was concluded that in rabbit the peritendinous adhesions following flexor tendon repairs could be lowered with Seprafilm and hyaluronic acid.

Reconstruction of soft tissue defects following total knee arthroplasty

Soft tissue defects following total knee arthroplasty can represent serious problems for the patient and the surgeon. Perioperative soft tissue complications can result in loss of the prosthesis or limb. In this study, we present 17 cases with complex wounds following total knee arthroplasty who had surgery between May-1994 and July-2001. Patient-related factors, wound factors, surgical operation, secondary procedures, and duration of follow-up have been analysed for each patient. After local wound care and debridement, soft tissue defects have been covered with either a fasciocutaneous or gastrocnemius myocutaneous flap. All the knees (100%) have been salvaged although in 1 patient (6%) replacement of the prosthesis was necessary. In 5 patients (30%) secondary surgical procedures have been performed. Even though there is no consensus in the management of soft tissue defects following total knee arthroplasty, adequate wound care, including identification of infection, debridement, and early appropriate defect coverage should be the main points to consider.

Reverse temporalis muscle flap for the reconstruction of orbital exenteration defects.

Orbital exenteration is a surgical procedure that results in devastating functional and aesthetic losses. Many reconstructive techniques, ranging from spontaneous epithelialization to free flaps, have been described for orbital exenteration defects. The temporalis muscle flap is one of the most frequently used flaps to obliterate the orbital cavity, but only a small portion of the muscle can be used for this purpose because most of the muscle is used as the pedicle. The reverse temporalis muscle flap based on the superficial temporal vessels is a versatile flap by which the entire temporalis muscle can be elevated and carried to defects beyond the midline. The authors have used this flap for orbital reconstruction after exenteration in 6 patients with successful results. This flap enables placement of highly vascularized tissue that provides the reconstructive goals of primary healing, obliterates dead space with separation of the orbit from the nasal cavity or sinuses, provides the potential for early postoperative radiotherapy, and offers possible flaps that can be used in combination for complex, wide defects.

Effects of Nerve Growth Factor on the Neurotization of Denervated Muscles

Studies on surgical repair techniques of the peripheral nerve are still trying to improve the outcome. There are many studies on the effects of various neurotrophic factors on the transected peripheral nerve. Muscular neurotization, which is the direct implantation of the nerve to the target denervated skeletal muscle, is one of the techniques used when the primary repair of the peripheral nerves is not possible. The effects of nerve growth factor (NGF), which is one of the primary neurotrophic factors, on the reinnervation of denervated muscles by neurotization is investigated in this experimental study. The denervated soleus muscle was neurotized via peroneal nerve implantation (group 1), and NGF was administered to the neurotized muscle (group 2). All animals were evaluated at weeks 8, 10, and 12 using electromyography. Muscle contractility, muscle weight, and histological morphometric tests were performed at week 12. The experimental groups were compared with each other and normal control values. Electromyographically, group 2 (direct nerve implantation + NGF) demonstrated better reinnervation in all evaluations. The study of muscle weight showed that the muscle mass was 75% of the normal soleus muscle in group 1 and was 85% of the normal side in group 2 at the end of week 12. In group 1, the twitch force was 56% of the normal soleus muscle and was 71% in group 2. Tetanic force was 53% of the normal soleus muscle in group 1 and 68% in group 2. Histological morphometric studies revealed that there was a decrease in the density of the motor end plates in group 1, but there was no statistically significant difference between the normal soleus muscles and the NGF applied to group 2. The positive effects of NGF on the neurotization of denervated muscles seen in this study suggest that it may be useful for treating some difficult reconstructions caused by denervation.

Adolescent growth patterns of the bony and cartilaginous framework of the nose: a cephalometric study.

Adolescent growth changes in the nose were studied for 140 female and 140 male subjects between the ages of 11 and 17 years who had class 1 skeletal and dental patterns. Age-related growth changes in the bony and cartilaginous framework of the nose were evaluated. Nasal height and nasal bridge length became fully mature in males at 15 years and fully mature in females at 12 years. The upper nasal dorsum, lower nasal dorsum, anterior nasal depth, and posterior nasal depth exhibited continuous growth up to 14 years in males and 2 years earlier in females. Nasal tip protrusion approached its mature size in males at 15 years and at 13 years in females. Although the lower dorsum rotated forward slightly, rotation of the upper dorsum was not significant during adolescence. Knowledge of these age-related growth changes of the nose may be useful in planning the time of aesthetic or reconstructive nose surgery.

Inverted, T-shaped silicone implant for the treatment of temporomandibular joint ankylosis.

Reconstruction of the ankylosed temporomandibular joint is a challenging task. Speech impairment, difficulties with mastication, poor oral hygiene, facial asymmetry, and mandibular micrognathia results in physical and psychologic disabilities. Various surgical techniques with varying success rates have been reported. Many autogenous and alloplastic materials have been proposed. The authors used an inverted, T-shaped silicone implant for the reconstruction of the temporomandibular joint after the release of the ankylosis in 10 patients without any complications in the postoperative period. The authors assert that the reconstruction of the ankylosed temporomandibular joint with an inverted, T-shaped silicone implant is a reliable and effective alternative. This technique can be used according to the special requirements of each patient and obviating the need for the fixation of the implant and is a safer and better way of using silicone for the treatment of temporomandibular joint ankylosis.

Increasing the Viability of Fat Grafts by Vascular Endothelial Growth Factor

OBJECTIVE To increase the viability of fat grafts using vascular endothelial growth factor (VEGF) in a calcium alginate microsphere controlled release system. DESIGN Twenty-four rats were divided into 4 groups of 6 rats each. Group 1 was the preconditioning group in which VEGF was applied prior to the fat grafting. In group 2,VEGF was given at the time of the grafting. In group 3, an empty microsphere was added to the grafting material. The fourth group, which received the fat graft only, was the control group. At the 90th day, samples of the fat grafts were weighed and compared with preimplantation weights. RESULTS The graft viability ratios of the first 3 groups were significantly higher than those of the control group. The relative adipocyte index was significantly higher in the first and second groups compared with the control group and group 3. Consistent with the literature, VEGF used both in the preconditioning procedure and simultaneously with the grafting procedure increased the graft viability ratio and relative adipocyte index. CONCLUSION This study suggests that VEGF-induced preconditioning of the recipient bed improves fat graft viability via increased revascularization.