Birol Civelek

The behavior of fat grafts in recipient areas with enhanced vascularity.

Fat grafts are used for soft-tissue augmentation of various anatomic regions, most frequently for the improvement of facial contours. Resorption of the graft is the main problem, and several different procedures have been described to minimize this phenomenon. Using 25 New Zealand rabbits, the behavior of fat grafts in a highly vascularized recipient site was studied. The recipient sites prepared on the backs of the rabbits were divided into four regions. A capsule formation with silicone sheet application was accomplished in two of these recipient areas before the transplantation of the fat grafts. Fat grafts were placed in the other two recipient areas without any prior preparation. We prepared two types of fat tissue; in one the lobular structure was preserved and in the other it was manually crushed and rinsed with lactated Ringers solution. The fat tissues with preserved lobular structure were placed in area I and area III. Manually crushed and rinsed fat tissues were placed in area II and area IV. In areas III and IV, a capsule formation with silicone sheet had been accomplished 3 weeks before grafting. Biopsy samples were obtained from these sites at the end of the first, third, sixth, and tenth months. Our aim was to observe the histologic fate of fat tissue in different recipient areas. The macroscopic and microscopic evaluation of the fat grafts in areas with silicone sheet indicated significant differences in the resorption time of the fat grafts; however, it was concluded that the significant resorption of the transplanted autologous fat tissue grafts at the end of the first year was an inevitable consequence of fat grafting.

Tangentially split gluteus maximus myocutaneous island flap based on perforator arteries for the reconstruction of pressure sores.

From 1995 to 1997, the authors used tangentially split gluteus maximus myocutaneous island flaps based on the musculocutaneous perforator arteries for the reconstruction of pressure sores located in the trochanteric, sacral, and ischial regions of 30 ambulatory and paraplegic patients. The postoperative follow-up period was 18 months. Postoperative electromyograms were performed on the ambulatory patients to compare the function of the gluteus maximus muscles on each side. There were one major and two minor postoperative complications. There was no total flap loss. The major advantage of this technique is the preservation of most of the gluteus maximus for stair climbing and single-limb support in the ambulatory patient. The tangentially split gluteus maximus myocutaneous island flap is recommended as the procedure of choice for closure of sacral, ischial, and trochanteric ulcers in both the ambulatory and nonambulatory patient.

Reconstructive options in severe cases of Hidradenitis suppurativa

Hidradenitis suppurativa is a chronic, debilitating inflammatory disease of apocrine glands characterized with abscesses and nodular lesions. The treatment of Hidradenitis suppurativa consists of topical antibacterial or antiseptic solutions, systemic antibiotics, steroids, hormonal therapy, anti-tumor necrosis factor, and various surgical procedures. In this report, we present a series of 14 cases with severe Hidradenitis suppurativa. Surgical options are reviewed to show the best outcomes in the long term. A total of 14 patients (9 female, 5 male) were treated for advanced cases of Hidradenitis suppurativa. They underwent excision of the affected regions followed by reconstruction. The reconstruction methods consisted of split-thickness skin grafting and various cutaneous and myocutaneous flaps. There was no flap necrosis or dehiscence. One patient developed contracture in the axilla, for which he underwent release surgery. There were recurrences in 4 cases. There was no limitation of the arm movements in cases with flap reconstruction. In the long-term, they were satisfied with the results. In conclusion, incision and drainage should be avoided because it is of limited value. Surgical removal of the involved tissue should be the first treatment of choice. Depending on the defect following excision, local flaps should be preferred over the grafts for recurrence prevention.

Denervated or innervated flaps for the lower lip reconstruction? Are they really different to get a good result?

OBJECTIVE: This study compares innervated and denervated flaps for the lower lip reconstruction in terms of oral sphincter function and sensation. STUDY DESIGN AND SETTING: A prospective trial. METHODS: This study was carried out on 31 patients with lower lip carcinoma. They were divided in 2 groups: 18 patients with denervated local flaps and 13 patients with innervated flaps. During the follow-up period, all patients were evaluated by electromyography tests and an assessment of the sensation on the lower lip and sphincter function was undertaken by clinical parameters. RESULTS: Compound muscle action potential (CMAP) was obtained in all patients. The amplitudes of CMAP were below normal and the values for distal motor latency (DML) were slightly longer than normal values. Interference patterns were observed on whistling in all cases. There were no differences in terms of sphincteric function in each group. CONCLUSIONS: The denervated random local flaps used for the lower lip reconstruction have no functional inferiority when compared to the innervated-pedicled local flaps. SIGNIFICANCE: This study demonstrates that denervated flaps can be employed for a functional lip reconstruction. EBM rating: B-2b

Management of pulse oximeter probe–induced finger injuries in children: report of two consecutive cases and review of the literature

Pulse oximetry is a standard noninvasive procedure for monitoring arterial oxygen saturation. Finger injuries related to pulse oximeter use have been reported as chemical or thermal burns, sun-tanning, pressure erosion, sensory loss, and gangrene. The mechanisms of these complications have not been definitively explained; but pressure ischemia, prolonged use, overheating of the probe, inappropriate use of the probe, and short circuiting are considered to be the main factors. We describe 2 cases of pulse oximeter probe-induced finger injuries, propose the possible mechanisms and factors related to the injury, and discuss the management.

Reconstruction of large meningomyelocele defects with rotation-transposition fasciocutaneous flaps.

AbstractMeningomyelocele is one of the most common congenital defects of the central nervous system. Reconstruction of these defects must be performed immediately after delivery to prevent complications such as primary meningitis and to protect the neural tissues. The most important factors in the surgical treatment of meningomyelocele defects are the size of the defect, its location, the presence of kyphosis, and the quality of the surrounding tissue. The chosen method must be a simple one that causes minimal blood loss, requires a short duration of surgery, and covers the surface of the neural defect with a soft-tissue mass enabling closure without tension. In our study, satisfactory results have been obtained using 1 or 2 fasciocutaneous flaps based on the midline in 20 patients with large meningomyelocele defects where primary closure was not possible. A single flap based superiorly on the midline was sufficient to close the defects in patients without kyphosis. In patients with concurrent kyphosis, a second flap based inferiorly on the midline has been used. All flaps survived, except for a distal partial necrosis observed in 1 patient. In the method we used, we adopted a defect reconstruction that is similar to the normal anatomic structures and resistant to trauma and infections, and does not sacrifice any muscle tissue. According to our clinical experiences, this method is useful for large meningomyelocele defects that are unsuitable for primary closure.

Intermittent ischaemia of skin flaps shortens time taken to divide pedicles: an experimental study in rats.

Ischaemic preconditioning increases the survival of flaps. Random–pattern McFarlane dorsal flaps were raised in 30 female Wistar rats, which were divided into three groups. An ischaemic conditioning protocol with clamping of the pedicle was used. No clamping was used in the control group, and the pedicle was clamped for 15 minutes in the second group and 20 minutes in the third group daily to see if the duration of ischaemia had any effects on the viability of the flaps. The pedicles were divided earlier in the clamped groups than in the control group. The size of necrotic areas of the flaps in the clamped groups was smaller than on the control group. Daily postoperative intermittent ischaemic conditioning in the pedicles of the flaps had a protective effect on their survival and led to earlier division of the pedicles.

W-plasty design of a bipedicled flap in lower extremity reconstruction

Sir, Bipedicle flaps have been successfully used for wound closure in a variety of anatomical sites like cleft palate, lower eyelid and lower extremity defects. Bipedicle flaps can be designed mucoperiosteal [1], musculocutaneous, fasciocutaneous, cutaneous, musculofasciocutaneous [2], subcutaneous [3] and V-Y modification [4, 5]. A soft tissue defect of the lower extremity, with the exposure of tendon or bone, represents a challenging reconstructive problem due to the lack of locally available tissue and relatively poor circulation of the skin. The closure techniques of soft tissue defects of the lower extremity include microvascular free tissue transfers, regional muscle flaps, local fasciocutaneous flaps and skin grafts for treatment of defects. Bilateral or unilateral bipedicle flaps can be used as a reliable method of immediate closure of difficult wounds in lower extremity reconstruction. These are commonly designed as fasciocutaneous, cutaneous and musculofasciocutaneous. The donor areas of these flaps are covered with a split-thickness skin graft in general. In our case, we designed a bipedicle flap where no skin graft was used for donor site closure. We used a w-plasty design for a bipedicled flap representing a similar pattern as hatchet flaps [6, 7] in a patient with a pretibial defect on the right side. A 58-year-old female had a right knee total revision prothesis surgery. Wound dehiscence occured on incision site and tibial bone was exposed. Under general anaesthesia, the wound was widely debrided. The medial part of defect with exposed bone was resurfaced with bipedicle flap designed in a w-plasty fashion. The lateral part of the defect was covered with a split-thickness skin graft (Fig. 1). The border of flap away from the recipient area was incised in a W design. The flap was raised in the subfascial plane. The multiple small trianguler flaps which formed after a W-shaped insicion were sutured to neighbouring trianguler flaps. The donor site was closed primarily with no skin grafting. The patient was followed up for 6 months without any complications noted in the surgical flaps (Fig. 2). We think the bipedicle w-plasty design provides reliable coverage with minimal donor site morbidity and abrogates the need for skin grafting. It can be used in regions where skin elasticity is reliable such as in face and trunk. Another benefit of this flap is that no new surgical wounds or sutures are placed near the original, difficult wound. For all these reasons cited above, we believe that a bipedicle w-plasty design should be added to the choices available to reconstructive surgeons. F. Tekin :Ö. F. Taner : C. Ceran : B. Civelek Department of Plastic and Reconstructive Surgery, Keçiören Training and Research Hospital, Ankara, Turkey

Yaygın oral tutulumlu skuamöz hücreli papillomun cerrahi eksizyon ve interferon alfa-2a ile kombine tedavisi

Objectives: Hepatitis C and interferon may trigger autoimmunity. We aimed to investigate the effects of combination treatment of peginterferon alpha (peg-IFN) + ribavirin in patients with chronic hepatitis C (CHC) on thyroid function tests and thyroid auto antibodies. Materials and Methods: The study included 45 outpatients with proven CHC having normal thyroid functions and previously not treated. The patients received combination of Peg-IFN+ribavirin. Values of fT3, fT4, TSH, antitiroglobulin (Anti-Tg) and thyroid peroxidase antibody (Anti-TPO) were measured at initial, fi rst, third and sixth months of treatment. Frequency of thyroid dysfunction was evaluated according to age and gender of patients. Results: Thyroid dysfunction emerged in 15 (%33.3) of 45 patients at the end of the six month of antiviral treatment. Symptomatic thyroid disease was confi rmed in 2 patients.Subclinical hyperthyroidism was determined in four patients (%8.9), and subclinical hypothyroidism in 3 patients (%6.7) at the end of third month.At the end of sixth month; symptomatic hyperthyroidism was observed in one patient (%2.2), subclinical hyperthyroidism in six (%13.3) and subclinical hypothyroidism in 7 patients (%15.6), and symptomatic hypothyroidism was determined in one patient (%2.2).At the end of the sixth month of antiviral treatment; Anti-Tg antibodies were positive in 12 patients (%26.7) and antiTPO in 11 patients (4 male and 7 female) (%24.5). No sig- nifi cant relationship was found between thyroid dysfunction and age, gender and ALT levels of patients (p>0.05). Conclusion: Periodic follow-up examinations should be done for thyroid autoimmunity and thyroid functions in CHC patients receiving combination treatment of PegINF+ribavirin.In adults, urethral foreign body is commonly observed with mental disorder, psychiatric or sexual behavior distursbance. In this paper, we reported a case which electrical cable wire was inserted into the urethra by the husband.Objectives: Dietary high fructose consumption which is closely associated with endothelial dysfunction via insulin resistance has recently increased in developed countries.Insulin resistance has a promoter effect on many meta-bolic disorders such as syndrome X, polycystic ovary syn-drome, Type 2 diabetes mellitus etc. Our aim in this study is to understand the impact of increased fructose intake on metabolisms of glucose, insulin and endothelial dys-function by measuring nitric oxide (NO) and endothelin-1(ET-1) levels in hepatic tissue which is crucial in fructose metabolism. Materials and Methods: We designed an animal study to understand increased fructose intake on hepatic en-dothelium. Twenty adult male albino rats were divided into two groups; the study group (group 1, n=10) received isocaloric fructose enriched diet (fructose-fed rats, con-taining 18.3% protein, 60.3% fructose and 5.2% fat) while the control group received purifi ed regular chow (group 2,n=10) for 2 weeks. After feeding period, blood and hepatictissue samples were collected and glucose, insulin, NO and ET-1 levels were analysed. Results: We found increased fasting glucose and insulin levels and impaired glucose tolerance in fructose fed rats. Higher NO and lower ETn1 levels were also detected in hepatic tissue samples of the group 1. Conclusion: Increased fructose consumption has delete- rious effects on glucose tolerance, insulin resistance and may cause to endothelial dysfunction. Key words: Fructose consumption, endothelial dysfunc-tion, nitric oxide, endothelin-1, liver.Oral squamous cell papilloma is a cutaneus lesions occurring due to human papilloma virus infections. These lesions spread locally and tend to have a high recurrence rate. Cases usually have a slow progression rather than acute symptoms. The course of disease is mostly subclinical. Although there are various treatment modalities which are recommended for the treatment of the disease, there is no particular and effective treatment modality that was proven. Limited surgical excisions result in frequent recurrences due to the presence of HPV in latent form around the lesions. Therefore, surgical excisions are combined with the other treatments such as systemically used interferons. We aimed to present a case of squmous cell papilloma with locally extensive lesions in the oral mucosa. Our patient was managed by the surgical excision and systemically given interferon treatment.

A perplexing presentation of a breast carcinoma: a case report

Breast cancer is a devastating disease for women. In this paper, we present a breast carcinoma presenting in a bizarre location. It was initially presumed that the patient had skin cancer, but the lesion turned out to be breast cancer presenting as a superficial mass on the skin of the breast.