Burak Kaya

Is it Possible to Prefabricate a Vascularized Peripheral Nerve Graft

The ideal technique to repair a damaged peripheral nerve is primary repair. Unfortunately, most damaged peripheral nerves have gaps making primary repair impossible. Autologous nerve grafts that are used to repair damaged nerves can either be conventional nonvascularized nerve grafts or vascularized nerve grafts. Vascularized nerve grafts are proposed to be superior to conventional nerve grafts especially in recipient beds that are scarred, with poor vascular supply. One of the disadvantages of vascularized nerve grafts is the limited donor site. It is possible to eliminate this problem by prefabricating vascularized nerve grafts. In this study, to prefabricate a vascularized nerve, segments harvested from left sciatic nerves of 10 Wistar albino rats were implanted on right femoral vessels, and intact right sciatic nerves were used as controls to evaluate the function, electrophysiologic studies, and histopathologic examination, were performed on these grafts 4 weeks after implantation. Prefabricated sciatic nerve grafts showed vascularization, but they did not show compound action potential activity to electrical stimulation and demonstrated diffuse and severe vacuolar degeneration and myelin loss. We were unable to prefabricate a functional vascularized nerve graft by this method.

Aplasia Cutis Congenita

A case of cutis aplasia with a full thickness defect involving scalp and cranium is presented. After a failedsurgical procedure healing was obtained conservative local treatment with the use of silvadene cream.

Comparison of the effects of systemic sildenafil, tadalafil, and vardenafil treatments on skin flap survival in rats

Abstract Objective: The most important issue in flap surgery is flap viability. This study aimed to compare the effects of most commonly used phosphodiesterase type 5 (PDE5) inhibitors on flap survival. Methods: A 3 × 9 cm flap was elevated from the dorsum of 32 Wistar albino rats. In the control group, saline was administered 2 hours before the flap elevation and continued for 2 days after the surgery. In the sildenafil, tadalafil, and vardenafil groups, the related drug was administered. Blood flow in the flaps was monitored with laser Doppler flowmetry. On postoperative day 7, flaps were photographed and biopsies were obtained. Results: The ratios of flap necrosis area in the tadalafil, sildenafil, and vardenafil groups were lower than that in the control group, but without significant difference (p = 0.077). Histopathological evaluation revealed no significant difference among the groups. Conclusion: The ratio of flap necrosis area tended to be lower in the groups receiving oral PDE5 inhibitors than in the control group, although not statistically significant. The role of PDE5 inhibitors needs to be evaluated in larger studies before a conclusion can be made regarding their effects on flap viability.

Comparison of ischaemic preconditioning with surgical delay technique to increase the viability of single pedicle island venous flaps: an experimental study.

Abstract The aim of the present study was to investigate the effect of ischaemic preconditioning compared with the surgical delay procedure in an effort to increase the survival rate of single pedicle island venous flaps. Eighteen male Wistar albino rats (250–350 g) were included. A 3 × 4 cm flap was planned at the right lower abdomen of the rat. Superficial epigastric vein constituted the pedicle of the flap. The rats were divided into three groups, each consisting of six rats. In the control group, a single pedicle venous island flap was elevated on each rat and no other surgical procedure was performed. In the ischaemic preconditioning group, ischaemic preconditioning was performed and, in the surgical delay procedure group, the surgical delay technique was performed before flap elevation. The mean necrosis areas were 56.85 ± 14.60%, 28.73 ± 15.60%, and 12.08 ± 3.65% in the control, ischaemic preconditioning, and surgical delay procedure groups, respectively. The necrosis areas were significantly smaller in the ischaemic preconditioning group and surgical delay procedure groups compared to the control group (p = 0.004 and p < 0.001, respectively). The necrosis areas were similar in the ischaemic preconditioning and surgical delay procedure groups. Histopathological parameters including necrosis, abscess formation, and skin ulceration scores were significantly lower in the ischaemic preconditioning group than in the control group, whereas the study groups were similar. In conclusion, ischaemic preconditioning may serve as an adjuvant technique in increasing venous island flap viability.

Physical Effects of Unilateral Mastectomy on Spine Deformity

Micro‐Abstract As mastectomy is known to effect body posture, we evaluated the long‐term physical effects of unilateral mastectomy on spine deformity by radiographic examination of 60 women taken before and 12 months after the mastectomy. The results indicated long‐term spinal deformation in women with unilateral mastectomy, suggesting informing patients of the possible change in body posture in the long‐term. Objective: Mastectomy is known to effect body posture after a change in the center of gravity of women due to a missing breast. Although previous studies on short‐term postural changes in mastectomy patients using photogrammetry or Moiré topography suggested ipsilateral inclination of the trunk, our clinical observations during breast reconstruction surgeries indicated a contralateral shoulder elevation in women with unilateral mastectomy. Because the change in body posture can affect spinal alignment, we aimed to evaluate the long‐term physical effects of unilateral mastectomy on spine deformity by radiographic examination. Methods: Posteroanterior chest radiographs of 60 women (mean age 56.3 ± 8.5 years) taken before and 12 months after the mastectomy were evaluated for Cobb angle and the presence or absence of a tilt from the midline in the coronal plane of vertebral body alignment. Results: Cobb angle decreased in 14 and increased in 38 of 60 patients after unilateral mastectomy, and the angular change was found to be independent of the mastectomy side (P < .001). A shift in Cobb angle to the mastectomy side was observed in 11 of 53 patients (P > .05), whereas a statistically significant shift in Cobb angle to the opposite of the mastectomy side was observed in 33 of 53 patients (P < .001). The results of this observational retrospective study indicated long‐term spinal deformation in women with unilateral mastectomy. Two patients with idiopathic scoliosis before mastectomy even developed scoliosis. Conclusion: We recommend informing the patients of the possible change in body posture in the long term, which should be supported or limited with physical therapy.

L-carnitine pretreatment protects slow-twitch skeletal muscles in a rat model of ischemia-reperfusion injury.

Ischemia–reperfusion (I/R) injury negatively affects the outcome of surgical interventions for amputated or severely traumatized extremities. This study aimed to evaluate the protective role of l-carnitine on the contractile properties of fast-twitch (extensor digitorum longus [EDL]) and slow-twitch (soleus [SOL]) skeletal muscles following I/R-induced injury in a rat model. Rats were divided into 4 groups (1) saline pretreatment, (2) l-carnitine pretreatment, (3) saline pretreatment and I/R, and (4) l-carnitine pretreatment and I/R. Twitch and tetanic contractions in the EDL and SOL muscles in each group were recorded. Additionally, a fatigue protocol was performed in these muscles. Twitch and tetanic contraction amplitudes were lower in the EDL and SOL muscles in which I/R was induced (P < .01). l-Carnitine pretreatment significantly increased tetanic contraction amplitude in the SOL muscles following I/R (P < .01) but not in the EDL muscles. l-Carnitine pretreatment did not alter the fatigue response in any of the muscles.

Effect of platelet glycoprotein IIb/IIIa receptor antagonist on survival of epigastric island flaps in rats with total venous occlusions.

We evaluated the effect of tirofiban hydrochloride on the survival of epigastric island flaps in rats that had had all the veins occluded. Male Wistar Albino rats were randomly assigned to control (treated with sterile saline) and experimental (treated with tirofiban hydrochloride 1 mg/kg intravenously) groups. An epigastric island skin flap 3×6 cm was raised in each rat. All veins that drained the flap were ligated to give total venous occlusion. Blood flow was recorded by laser Doppler preoperatively (baseline), immediately after the flap had been sutured back to its original position (acute) and on postoperative days 1 and 3. The degree of necrosis was evaluated on day 3. Mean percentage necrosis and minimum laser Doppler values were compared in the two groups. Total necrosis was evident on day 1 in the control group and on day 3 in the experimental group. Macroscopic evidence was confirmed by histopathological examination. There were appreciable differences in blood flow and in the necrotic area of the flap in the experimental group compared with the control group on both days 1 and 3. Tirofiban hydrochloride might be effective in this flap model.

A simple and effective method to optimize limb position after complex lower limb free flap reconstruction with concurrent external fixation

Dear Sirs, In complex lower extremity reconstruction following trauma, immobilization with external fixation may add an ergonomic obstacle to performing a comfortable and efficient-free flap surgery. In addition, positional changes of the limb may compromise the venous circulation of the flap. In this regard, various postoperative measures such as limb positioning, external fixator devices, and regular compression stockings have been described in an attempt to decrease post-operative edema and reduce potential complications (Castro-Aragon, Rapley, & Trevino, 2009; Unal & Gercek, 2012). Herein, we share a simple customizable solution that aids immediate postoperative extremity immobilization in the position of optimal flap perfusion. An external scaffold is individually constructed for each patient by the surgeon postoperatively using long solid struts of Zimmer splints reinforced and enclosed within plaster of Paris (POP). The Zimmer splint scaffold is formed in an “H” format and is fully customizable before the POP sets to interact with the external fixation hardware, maintaining the limb in a stable and safe position with the desired elevation (Figure 1). This scaffold is especially useful to safeguard large flaps with a single venous anastomosis, as they might be sensitive to positional changes. From November 2010 to June 2017, we applied this scaffold in 22 patients who underwent complex lower extremity orthoplastic procedures with free flaps and have seen no position-related flap complications nor heel ulcers. The stable construct immobilizes the limb in this position of optimal perfusion and avoids unpredictable variables of the patient moving and pillows dislodging, both during transfer and subsequently on the ward (Klein, Luster, Green, Moore, & Cape, 1988). This solution is a simple, effective, and cheap alternative option to expensive or convoluted modifications to the external fixation device and achieves the same end, especially in practices with low resources.

A simple and effective crepe bandage splinting method to decrease tension after large superficial circumflex iliac artery perforator (SCIP) flap donor site closure

Dear Sir, The superficial circumflex iliac artery perforator (SCIP) flap has reached widespread popularity due to its ability to provide a large, pliable, hairless and thin skin paddle with low donor site morbidity (Hong, Sun, & Ben-Nakhi, 2013; Koshima et al., 2004). A potential complication of the SCIP flap when pushing the limits of its dimensions is donor wound dehiscence. Herein, we share a simple crepe bandage splinting method that can be easily employed to reduce this risk. In our practice, all patients who undergo reconstruction with a large SCIP free flap (over 7 cm width) are managed with a splint to immobilize the ipsilateral hip region in the immediate postoperative period. After dressing the donor site, the patient’s knee is flexed to 90 degrees with slight external rotation of the hip joint and crepe bandaging is firmly applied spanning the thigh and lower leg in a figure-of-eight manner (Figure 1). This reliably maintains the hip and knee in flexion when the patient is supine reducing biomechanical tension across the wound closure. The position is maintained for one week at which time the splint removed and gradual mobilization is started under supervision to facilitate mobilization of the knee while avoiding excessive inadvertent hip extension. We have noticed no adverse effects of this with only transient hip and knee stiffness that quickly resolves and no impact on duration of admission. The SCIP flap is becoming a new workhorse flap in reconstructive surgery (Hong et al., 2013; Peter & Hong, 2016). After flap harvest, it is mainly the width of the flap, rather than its axial length, which is the limiting factor in achieving direct closure. The current literature reports a maximal flap width of 11 cm (Chao, Wang, Chen, & Chen, 2016) when elevated without other loco-regional perforators. Larger dimensions can be achieved when other loco-regional perforators are recruited in a mosaic flap manner. (Chao et al., 2016; Nicoli et al., 2016) In such cases, this splinting technique may be especially useful. Common postoperative adjuncts to mitigate the risk of dehiscence include limiting ambulation, maintaining the bed in a position of leg elevation, the use of pillows and other bolsters to maintain hip flexion, and incisional negative pressure wound therapy (Peter & Hong, 2016). The technique described has been utilised successfully in 42 patients with a mean flap width of 10 cm and no attendant donor wound dehiscence. Serendipitously, we have noticed a reduction in donor site seroma that may be related to immobilization of the donor site area and resultant minimization of friction along the tissue planes. While it requires involvement of the nursing staff and a physiotherapist during the initial mobilization, this simple technique can facilitate harvest of maximal flap dimensions while reducing the risk of donor site dehiscence.

Pilomatricoma in the Upper Extremity after Vaccination: A Case Report

Pilomatricoma (also known as pilomatrixoma) is a rare benign skin tumor arising from hair follicle stem cells; it is also known as calcifying epithelioma of Malherbe. A definitive diagnosis can be made by histopathological examination. Surgical excision of the lesion is recommended for its treatment. The lesion can often be misdiagnosed when differential has not been considered. In the literature, there are few reports of pilomatricoma cases occurring after vaccination. A 21-month-old male patient was admitted to our clinic with a mass on his left arm that occurred after vaccination. The lesion was completely excised. The diagnosis of pilomatricoma was made after histopathological examination. As there were no predisposing factors other than vaccination, we concluded this to be a complication of the vaccination. The pathogenesis of pilomatricoma is unclear, but inflammation and trauma may promote neoplastic development. We report this case to draw attention to this rare lesion and to the possible etiopathogenetic association of vaccination with pilomatricoma.