Atilla Arinci

Ultrasonographically determined pedicled breast reduction in severe gigantomastia.

Background: The free nipple breast reduction method has certain disadvantages, such as nipple hyposensitivity, loss of lactation, and loss of projection. To eliminate these risks, the authors describe a patient-based breast reduction technique in which the major supplier vessels of the nipple-areola complex were determined by color Doppler ultrasonography. Pedicles containing these vessels were designed for reductions. Methods: Sixteen severe gigantomastia patients with a mean age of 41 years (range, 23 to 60 years) were included in the study. Major nipple-areola complex perforators were determined with 13- to 5-MHz linear probe Doppler ultrasonography before surgery. Pedicles were designed according to the vessel locations, and reductions were performed with superomedial-, superolateral-, or mediolateral-based designs. Results: Different combinations of internal mammary and lateral thoracic artery perforator–based reductions were achieved. None of the patients had areola necrosis. Mean reduction weight was 1795 g (range, 1320 to 2280) per breast. Conclusions: Instead of using standard markings for severe gigantomastia patients, custom-made and sonographically determined pedicles were used. This technique can be considered as a “guide” for the surgeon during very large breast reductions.

Does partial expander deflation exacerbate the adverse effects of radiotherapy in two-stage breast reconstruction?

BackgroundThe optimum protocol for expander volume adjustment with respect to the timing and application of radiotherapy remains controversial.MethodsEighteen New Zealand rabbits were divided into three groups. Metallic port integrated anatomic breast expanders of 250 cc were implanted on the back of each animal and controlled expansion was performed. Group I underwent radiotherapy with full expanders while in Group II, expanders were partially deflated immediately prior to radiotherapy. Control group did not receive radiotherapy.The changes in blood flow at different volume adjustments were investigated in Group II by laser Doppler flowmetry. Variations in the histopathologic properties of the irradiated tissues including the skin, capsule and the pocket floor, were compared in the biopsy specimens taken from different locations in each group.ResultsA significant increase in skin blood flow was detected in Group II with partial expander deflation. Overall, histopathologic exam revealed aggravated findings of chronic radiodermatitis (epidermal atrophy, dermal inflammation and fibrosis, neovascularisation and vascular changes as well as increased capsule thickness) especially around the lower expander pole, in Group II.ConclusionsExpander deflation immediately prior to radiotherapy, may augment the adverse effects, especially in the lower expander pole, possibly via enhanced radiosensitization due to a relative increase in the blood flow and tissue oxygenation.

Free pre-expanded lateral circumflex femoral artery perforator flap for extensive resurfacing and reconstruction of the hand

Resurfacing and reconstruction of extensive scars, severe contractures and deformities of the hand are still challenging cases for plastic surgeons. Treatments usually necessitate thin, pliable and broad flaps. Additionally, minimising the donor-site morbidity is an indisputable requisite. The pre-expanded perforator flap technique has been shown to provide extensive, thin and pliable skin with increased vascularity while reducing the donor-site morbidity. Utilisation of free pre-expanded lateral circumflex femoral artery perforator flap in an aesthetic and functional reconstruction of severe post-burn hand deformity is demonstrated. The successful functional and aesthetic outcome that was achieved in the early postoperative period and which still persists after 23 months of follow-up indicates that our technique could be preferably used in the extensive coverage of the hand.

The effect of parenteral pentoxifylline therapy on skin flap survival

SummaryThe effect of pentoxifylline as a hemorrheologic agent on skin flap survival has been observed. A caudally pedicled dorsal flap with an ischemic component in rats was used as the model. The flap survival was calculated to be 0.807±0.049 in the control group (n = 15), where flap survival was found to be 0.9713±0.018 in the pentoxifylline treated group (n = 15) (t = 12.19, p < 0.005). In the meantime, living flap length was measured as 9.96±0.72 in the control group, and 11.84±0.18 in the pentoxifylline treated group. With these results, we have come to the conclusion that parenteral pentoxifylline therapy is effective on ischemic skin flap survival in the rat model.

A nomogram for predicting the degree of breast augmentation according to implant size.

Choosing the right implant size for a specific patient is a challenging aspect of breast augmentation. Bust circumference is obtained by measuring the chest circumference at the level of the nipple-areola complex. Pre- and postoperative bust circumference measurements obtained from 147 patients who underwent primary bilateral breast augmentation using round, textured, gel-filled implants were evaluated, and a practical reference list for future operations was developed. According to the results, each additional 100 ml in implant size yielded an approximate 2-cm increase in bust circumference. The authors believe these results gathered from systematic measurements may serve as a useful guide for choosing the right size implant for a satisfactory augmentation procedure.

Self-rejuvenation of the hand:

Dear Sir, Self-injection of various materials for cosmetic purposes appears to be increasing in incidence (Hazani and Engineer, 2008). The face and hands, as the most conspicuous parts of the body, are potentially the most likely targets of such rejuvenation procedures. The hand dorsum has not, to our knowledge, been previously reported as a site of self-injection. We report a case of paraffinoma caused by repeated self-injections of baby oil to the dorsum of both hands. A 51-year-old woman was referred for having injected her face and hands with baby oil repeatedly during a 5 year period, with the most recent injection having been performed 7 years previously. She experienced no adverse symptoms initially. Immediately following the last injection 5 years ago, she had an acute attack of anaphylactic symptoms with massive swelling at the injection sites, and was treated with systemic steroids and antihistamines. The initial generalized swelling on the back of her hands yielded to hard, inflammatory lumps and no treatment had been employed to this area except some amateur tattooing for camouflage. On physical examination, the skin on the dorsum of the hands was erythematous and the inflammatory lumps were visible by direct inspection. Although the overall metacarpophalangeal joint mobility was not restricted, the dorsal skin had lost its mobile and pliable quality and become fixed to the subcutaneous mass which could be observed to move in accordance with tendon motion (Fig 1). An incisional biopsy was taken under local anaesthesia from the hand dorsum and samples were sent for pathology and microbiological examination. Cultures for aerobic and anaerobic bacteria, mycobacteria and fungi were negative. Findings of the pathological examination were consistent with sclerosing lipogranulomatosis. Our therapeutic approach consisted of conservative treatment with close follow-up evaluation, since the patient declined to undergo surgery for complete excision of all involved tissue. Hand augmentation is an important component of hand cosmesis. Although volume replacement is usually performed to restore the youthful fullness to the dorsum of the aging hand, it can also be used for younger patients with innately thin hands and deep intermetacarpal spaces with arthritic appearing joints. Our patient stated that she had always been unhappy with the ‘wasted’ appearance of her hands and decided to try the baby oil injections here as well. In female patients presenting with chronic dorsal hand oedema, the differential diagnosis includes factitious disorders such as Secretan’s disease orMunchausen syndrome (Al-Qattan, 2001). Some reports describe both Secretan’s disease and Munchausen syndrome to be similar to our case where patients ‘were sad and unhappy’ (Wallace and Fitzmorris, 1978). However, in cases where cosmetic self-improvement is the main aim, the patient readily admits that the pathology was self-inflicted, whereas in the latter two, secondary gain with attention seeking behaviour predominates and the patient denies the act. Self-injection of various home-made fillers by psychologically unstable patients for cosmetic purposes has become a relatively common problem (Tümerdem et al., 2004). It should be kept in mind that hands can also be the target for these procedures. Proper management should involve biopsies to rule out superimposed fungal, mycobacterial or other chronic infections, followed by an attempt to surgically excise all involved tissues where

False aneurysm of the princeps pollicis artery of the hand

Aneurysms of the arteries of the wrist and hand are uncommon, and traumatic aneurysm of the princeps pollicis artery is extremely rare. In this paper, a 24-year-old man who had a traumatic aneurysm of the princeps pollicis artery in his right wrist is presented.