Anı Cinpolat

Superiority of medial circumflex femoral artery perforator flap in scrotal reconstruction.

Scrotal skin has unique cosmetic and functional features that make its reconstruction difficult. Coverage of the testicles and constituting a good cosmetic appearance are major expectations from a successful reconstruction. Usually flaps are the choice for scrotal reconstruction, but every single flap has its own characteristics. In our series, between January 2006 and January 2010, the medial circumflex femoral artery perforator flap was used in 7 male patients for scrotal coverage after Fournier gangrene. Six flaps were raised based on a single perforator from the gracilis muscle; however in one flap 2 perforators were used. Flaps were carried to the defect either by transposition or by V-Y advancement. Donor areas were closed directly in all patients, and stable scrotal coverage was achieved with an acceptable scrotal contour and cosmesis. No major complication was seen due the perforator flap surgery, in 2 patients wound dehiscence were noted and they healed by secondary intention or by secondary suturing. For scrotal reconstruction, the medial circumflex femoral artery perforator flap is a good option with its good mobility, thinness for scrotal contour, possibility for muscle preservation, and direct closure of the donor site. All these advantages can be accomplished in 1 procedure.

True Functional Reconstruction of Total or Subtotal Glossectomy Defects Using a Chimeric Anterolateral Thigh Flap with Both Sensorial and Motor Innervation

BackgroundThe purpose of this study was to report the motor functional outcomes and sensory recovery of patients who had undergone total or subtotal glossectomy for oral squamous cell carcinomas reconstructed with chimeric anterolateral thigh (ALT) flaps. MethodsSix patients, 4 men and 2 women, with a mean age of 49.5 years (range, 36–73 years) were included in the study. All patients were treated with chimeric ALT, including the vastus lateralis muscle with its motor nerve and skin paddle with its innervating nerve. All patients were administered functional tests involving sensory recovery, intelligibility, and swallowing. Flap sensibility was evaluated using light touch sensation with the Semmes-Weinstein monofilament test, 2-point discrimination according to the Weber sensitive test, warm and cold temperature sensations, and pain sensation. Intelligibility was scored by a speech therapist on a scale from 1 to 5. Swallowing was assessed by electromyography, deglutition scores (on a scale of 1 to 8), and modified barium swallow. Donor-site morbidities were recorded. ResultsMean follow-up was 26.6 months (6 months-5 years). The flaps were successful in all 6 patients. The donor site was closed primarily and no complications were seen in the follow-up period. Normal extension of the knee joint and no evidence of lateral patella instability occurred. Speech intelligibility was good (4) in 3 patients and acceptable (3) in 3. Deglutition scores were 6 in 2 patients, 5 in 2, and 4 in 2. Modified barium swallow revealed that 4 patients experienced bolus transit, but 2 required a liquid swallow to promote bolus transit. Electromyographic recordings showed innervations of the vastus lateralis muscle with active generation of motor unit potentials in 4 patients when trying to elevate the tongue. This was not performed in 1 patient, and 1 other had macroscopic muscle contractions. All sensory tests were satisfactory in all parameters. ConclusionsThe results of this reconstructive option were satisfactory in terms of motor function and sensitive assessment of the neotongue. This technique is strongly recommended for patients with total or subtotal glossectomy.

Metatarsal artery perforator-based propeller flap.

Soft‐tissue defects of the distal foot that involve an exposed tendon and bone demonstrate a reconstructive challenge for plastic surgeons. This report investigates the feasibility and reliability of metatarsal artery perforator (MAP)‐based propeller flap for reconstruction of the distal foot soft‐tissue defects. Between July 2011 and June 2012, six patients underwent distal foot reconstruction with seven MAP‐based propeller flaps. Five flaps were based on the third metatarsal artery and two flaps were based on the first metatarsal artery. The flap size ranged from 4 × 2 cm to 8 × 4 cm. All flaps completely survived. Two patients developed transient distal venous congestion, which subsided spontaneously without complications. There were no donor site complications. All patients were ambulating without difficulty within the first month of surgery. MAP‐based propeller flaps can be used to repair the distal foot soft‐tissue defects, providing sufficient skin territory and excellent esthetic and functional recovery.

Reconstruction of distal lower extremities defect using the free peroneal artery perforator vessel based flap

Soft tissue defects of the distal lower extremities are challenging. The purpose of this paper is to present our experiences with the free peroneal artery perforator flap for the reconstruction of soft tissue defects of the distal lower extremity. Nine free peroneal artery perforator flaps were used to reconstruct soft tissue defects of the lower extremities between April 2006 and October 2011. All flaps were used for distal leg and foot reconstruction. Peroneal artery perforator flaps ranged in size from 2 cm × 4 cm to 6 cm × 12 cm. The length of the vascular pedicle ranged from 2 to 6 cm. Recipient vessels were: medial plantar vessels in seven cases, the dorsalis pedis vessel in one, metatarsal vessel in one. All flaps survived completely, a success rate of 100%. Advantages of this flap are that there is no need to sacrifice any main artery in the lower leg, and minimal morbidity at the donor site. This free perforator flap may be useful for patients with small to medium soft tissue defects of the distal lower extremities and feet.

Comparing different postconditioning cycles after ischemia reperfusion injury in the rat skin flap.

AbstractIschemic postconditioning is a useful manipulation to reduce the undesirable effects of ischemia-reperfusion (I/R) injury. The beneficial results of this phenomenon against I/R injury have been seen in several flap models. However, there are no published works comparing different postconditioning (post-con) cycles in skin flaps. In this study, we investigated the effectiveness of different post-con cycles in a skin flap model. Epigastric island flap (6 × 3 cm) model which was based on the left superficial epigastric artery and vein was used, and complete 6 hours of ischemia was generated by occlusion of the pedicle. Forty male Wistar rats were allocated into 5 groups (n = 8 in each group). Group 1 (sham group): the elevated skin flap was repositioned without an episode of ischemia. Group 2 (control group): skin flap was elevated and 6 hours of complete ischemia was induced by clamping the pedicle. Group 3 (post-con 1): After ischemia, post-con was performed by 6 cycles of 15 seconds of repeated I/R periods. Group 4 (post-con 2): After ischemia, post-con was performed by 6 cycles of 30 second of repeated I/R periods. Group 5 (post-con 3): After ischemia, post-con was performed by 6 cycles of 60 second of repeated I/R periods. Flap viability was assessed 1 week after the surgical procedure, the necrotic area of the skin flap was measured using image analysis on the computer. The area of flap necrosis was statistically significant between the control and post-con group 4 and group 5, and no statistically significant difference was obtained between the control and post-con group 3. Groups 4 and 5 demonstrated lesser area of flap necrosis than the control group and group 4 was superior to group 5. The results revealed that the post-con applied by means of 6 cycles of 30 seconds yields the best protection against I/R injury in the rat skin flap model.

Complex partial nasal reconstruction using free prelaminated temporoparietal fascial flap

The reconstruction of nasal defects together with nasal lining, skeletal support, and skin loss constitutes difficulty to plastic surgeons. We present a single‐stage reconstruction of the defect formed on the nasal tip, columella, septum, and upper lip after tumor excision by performing free temporoparietal fascial flap, costal cartilage, and skin graft. In this case, cartilage support was created by the graft taken from costal cartilage, and free temporoparietal fascial flap was wrapped around this cartilage scaffold. Skin graft taken from scalp was placed on the skin surface, and skin graft taken from the thigh was placed on the mucosal surface. Vascular anastomoses were performed on the labial artery and the concomitant vein. In consequence of this operation, a nasal reconstruction with acceptable esthetic and functional results was provided in a complex nasal defect. Internal lining, skin, and cartilage structures were replaced in one single stage and with single flap and graft.

Comparing the effects of pedicle torsion on axial or perforator flaps; improving the perforator flap resistance to pedicle torsion with delay phenomenon.

BACKGROUND The torsion of the flaps pedicle is one of the most common conditions causing vascular compromise. We aimed to compare the resistance to torsion of axial flap pedicle and perforator pedicle patterns. In the second part of the study, we investigated whether the delay phenomenon is an effective method for improving perforator flap resistance to pedicle torsion. METHODS In the first phase, 90 male Wistar rats were randomly divided into two groups: perforator and axial. Bilateral groin flaps were elevated in the axial group and bilateral posterior thigh perforator-based flaps were elevated in the perforator group. Viable flap areas were compared at 90, 180, 270, 360, and 720 degrees of pedicle rotation. Microangiographic and histopathological studies were performed. RESULT As a result, necrosis was seen following earlier rotation in the perforator group and viable flap areas were also lower. In the second phase, after delay procedure, the perforator flaps were exposed to 270, 360, and 720 degrees of pedicle rotation. With the delay procedure, no significant difference in viable flap areas was observed. CONCLUSION In conclusion, the resistance to torsion of the axial flap pedicle pattern was greater than that of the perforator pedicle pattern, and the delay procedure was not an effective method for improving flap resistance to torsion.

Comparing various surgical delay methods with ischemic preconditioning in the rat TRAM flap model.

Both surgical delay and ischemic preconditioning (IP) have been shown to be effective in improving the survival of flaps. We used a variety of flap delay methods and IP to increase the surviving area of the transverse rectus abdominis musculocutaneous (TRAM) flap in rats, and the results are compared in between. A 6-× 3-cm-sized TRAM flap in 40 Wistar rats was allocated into five groups. Group 1: TRAM flap was elevated from nondominant pedicle, and the flap was sutured to the original bed. Group 2: Left superior deep epigastric vessels (SDEV) were cut; 1 week later, TRAM flap was elevated. Group 3: Only skin incision was done; 1 week later, TRAM flap was elevated. Group 4: Skin incision was done, and the left SDEV were cut; 1 week later, TRAM flap was elevated. Group 5: TRAM flap was elevated; IP was performed using three cycles of 10 minutes of repeated ischemia/reperfusion (I/R) periods, and the flap was sutured to the original bed. The surviving area of the flap was statistically significant between the control and groups 2, 4, and 5 (p < 0.001), and groups 4 and 2 were superior to group 5. Although preconditioning has been intensively studied for the last two decades and partly provided its beneficial effects in I/R injury, we determined the IP increased the surviving area of the TRAM flap but not effective as much as surgical delay method.

Reconstruction of Lateral Lower Lip Defects With Transverse Lip Advancement Flap

BackgroundLower lip defects between one and two thirds of the lower lip are usually reconstructed with neighboring tissues from the upper lip, cheeks, or the mentum or a combination of these tissues. In this article, we offer a simple and effective reconstruction option that can be used for lateral defects between one third and two thirds of lower lip tissue. Utilizing the tremendous flexibility and expandability of the lip tissue, we tried to minimize the incisions and scar, and maximize the sensation and function with transverse advancement flap. Patients and MethodsTen patients with lateral lower lip defects, after tumor ablation, were treated by this technique. After excision of tumor, the existing incision is extended to medial by following the natural labiomental crease. Full-thickness incision is ended at the level of commissure not to disturb the buccal and marginal mandibular branches of the facial nerve. Intraoral incision is made 1 cm above the gingivobuccal sulcus .The mental nerve was dissected and preserved to keep the sensorial innervation of the lower lip. Thus, transverse advancement labial flap that includes the orbicularis oris with intact neurovascular supply is freed to provide the desired advancement. ResultsSatisfactory functional, aesthetical, and sensational results were obtained. ConclusionA dynamic reconstruction can be provided with superior results in terms of lip appearance and function with transverse lip advancement flap. In planning a lip reconstruction, we think that transverse lip advancement flap should be considered as a second ladder after primary closure.

Consideration of difficulties and exit strategies in a case of face allotransplantation resulting in failure

We describe the first rescue procedure in a case of total face allotransplantation. The recipient was a 54‐year‐old man with severe disfigurement of the entire face following an accidental gunshot injury 5 years previously. The large defect included the maxilla, mandible, and mid‐face. Full face procurement was performed from a multiorgan cadaveric donor and was allotransplanted to the recipient. The post‐transplant induction immunosuppressive regimen included ATG combined with tacrolimus, mycophenolate mofetil, and prednisone, while maintenance was provided by the last three of these. Although the early postoperative period was uneventful, squamous cell carcinoma developed in the upper and lower extremities in the fifth postoperative month, and post‐transplant lymphoproliferative disorder (PTLD) occurred in the sixth month postoperatively. Malignancies were treated, involving both surgical and medical approaches. The patient developed opportunistic pulmonary and cerebellar aspergillosis. In order to reduce the adverse affects and metabolic and immunological load, the transplanted face was removed and replaced with a free flap. Although the early postoperative period was promising, with the transferred flap surviving totally and all vital signs and general status appearing to be improving, the patient was eventually lost due to complicated infectious and metabolic events. Although this case was unsuccessful, we suggest that the immunological and metabolic load should be reduced as soon as stable medical conditions are established in case of diagnosis of a situation involving a high rate of mortality, such as PTLD and untreatable opportunistic infections. This should include withdrawal of all immunosuppressive drugs and removal of all allotransplanted tissues.