Burcu Çelet Özden

Dorsal metacarpal island flap in syndactyly treatment.

Web space reconstruction is an important component of syndactyly treatment. There are several methods for a skin graft–free reconstruction. Previously, the dorsal metacarpal island flap based on a direct cutaneous branch of the dorsal metacarpal artery has been used as an island V-Y advancement for web defects in syndactyly. In this study, dorsal metacarpal artery flap was raised similarly as an island but was used instead as a transposition flap in a series of 19 web defects. Early results of a median (range) follow-up of 3 (1–5) years reveal neither recurrence of the deformity nor web creeping. Such utilization of the flap enables a better use of the skin territory proximal to the pedicle and a more comfortable reconstruction of the web space.

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.

Electrothermal Bipolar Vessel Sealer in Endoscope-Assisted Latissumus Dorsi Flap Harvesting

LigaSure™ is a new bipolar vascular sealing system commonly used in various fields of surgery. However, no reports have been published about its use in plastic surgery, particularly for endoscopic flap harvesting. In this study, we present the use of LigaSure in endoscope-assisted latissimus dorsi (LD) flap harvesting for breast reconstruction. Between 2006 and 2008, 11 female patients with the mean age of 33.4 (range, 20-49 years) who had previously undergone mastectomy operations were included in the study. First stage of reconstruction was performed with the ipsilateral LD harvested by the help of LigaSure and a tissue expander placed beneath the LD and pectoralis major muscles. Secondary reconstruction was done by a definitive silicon gel-filled implant placed after an average of 6.6 months of expansion (range, 6-9 months). Data concerning the hospitalization and operation times, drainage amounts, complications, etc., were recorded. Mean follow-up was 13 months (range, 8-18 months). Mean flap harvesting time was recorded as 74.2 minutes (range, 50-125 minutes), which shortened as the surgeon got used to the procedure. Patients were hospitalized for 3-7 days, with a mean hospitalization period of 5.5 days. The total mean drainage amount postoperatively was found to be 950 mL (range, 725-975 mL), which is relatively lower than the previously reported values. LigaSure use in endoscope-assisted LD harvesting is easy, safe, and time sparing with almost no complications observed in this small initial series. Although more controlled studies with larger number of patients need to be done to verify its effectiveness in terms of hospitalization, drainage amounts, etc., it holds promise for a wide spectrum of operations in the field of plastic surgery.

The use of the ipsilateral versus contralateral pedicle and vertical versus horizontal flap inset models in TRAM flap breast reconstruction: The aesthetic outcome

The use of an ipsilateral or a contralateral rectus abdominis muscle as a pedicle and comparison of their advantages and disadvantages in TRAM flap breast reconstruction have been reported in the literature. In our clinical experience with 22 pedicled TRAM flap breast reconstructions, the use of either an ipsilateral or contralateral pedicle was found to be equivocal regarding the flap viability and the aesthetic outcome. Thus, it seems better to decide their use according to the needs of an individual patient.In our series, the contralateral pedicled TRAM flap with a vertical flap inset was preferred in patients with a small opposite breast or in patients with infraclavicular tissue losses (four patients). The ipsilateral pedicled TRAM flap reconstruction with a horizontal flap inset was preferred in patients with a full and attractive opposite breast, unless they received adjuvant radiotherapy (six patients). In patients who received adjuvant radiotherapy the contralateral pedicle was used regardless of the inset model preferred (10 patients). Bilateral TRAM flap breast reconstruction was applied in one of our cases, which is not included in the three categories above mentioned. The aesthetic outcome was determined by analyzing a patient satisfaction questionnaire. Overall satisfaction was achieved in 17 patients. Four patients were dissatisfied.We think that choosing the correct flap inset model is one of the most important factors in achieving a satisfactory aesthetic outcome. Choosing the correct pedicle regarding the type of the flap inset model is equally important to facilitate technical ease during flap transposition and to improve flap survival.

Use of free serratus anterior muscle slips for the reconstruction of dorsal-side defects of the hand resulting from hot press injury.

Mutilation of the hand as a result of hot press injury, the common characteristics of which are extensive soft tissue and extensor tendon loss, metacarpal and phalangeal necrosis, exposition of multiple joints, and infection, presents a serious challenge to the hand surgeon. Free transfer of the inferior three slips of the serratus anterior muscle is a useful surgical option for the reconstruction of dorsal-side defects in the hand. The versatility of the three separate slips, which are easily divisible for contouring, enables individual reconstruction of the different digits. Long vascular pedicle, low donor-site morbidity, and durability are other advantages. Four male patients with hot press injury of the dorsal side of the hand were treated with free transfer of serratus anterior muscle slips and split-thickness skin grafts. Follow-up period ranged between 5 and 12 years. Late functional and cosmetic results are presented.

Lower eyelid reconstruction in a paediatric face: A one-stage aesthetic approach using the versatile temporoparietal fascia flap

There are many different lower eyelid reconstruction techniques defined in the literature. Almost all of the published techniques have been described on elderly patients and use upper eyelid, periorbital or facial tissues as donor sites. However, in case of a paediatric patient or a young adult who has a crease-free and scarless face, camouflage of the facial donor-site scar is usually impossible. In order to avoid possible facial donor-site scars and upper eyelid deformities, a technique which uses the temporoparietal fascia (TPF) flap as the framework of a new eyelid was used for the reconstruction of an adolescent patients postoncologic defect. The inner side of the flap was covered with nasal septal chondromucosal graft and the external side was covered with a retroauricular full-thickness skin graft. Eighteen months of unproblematic follow-up of this overlooked usage of the versatile TPF flap indicates that our technique has proved successful in terms of good functional and cosmetic outcome that is obtained at one stage.

Quadruple salivary duct diversion for drooling in cerebral palsy.

Abstract Drooling complicates many neurologic disorders including cerebral palsy. It is socially debilitating for the patient and very tedious for the caregiver. Surgical treatment consists mainly of ablative (excision/ligation) or physiological (diversion) methods; combined techniques have also been proposed. We have applied bilateral diversion of both submandibular and parotid ducts in 12 cerebral palsy patients (age range, 7–15 years). Preoperative drooling severity was grade 4/5 in 10 cases and grade 5/5 in 2 of the cases. All patients underwent physiotherapy for a minimum of 6 months and were consulted with a dentist, otolaryngologist, and a speech therapist before surgery. No bleeding, hematoma, or infection has been observed in any of the patients. Two patients had early postoperative tongue edema that regressed with conservative treatment. All patients except one regressed to grade 2/5 drooling by the first postoperative month. In 1 patient who had previously been classified as grade 5/5, surgery provided limited improvement with only 1 grade of step-down. Satisfactory results for the patients and their families could be achieved and sustained for a median 18 months (7–20 months) of follow-up. In conclusion, the quadruple duct diversion method is an effective physiological surgical method in the control of drooling in cerebral palsy.

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.

A practical dressing method after nipple–areola reconstruction: the syringe stent

Dear Sir, A number of techniques have been introduced for nipple– areolar reconstruction as part of breast reconstruction following mastectomy. The two main approaches to nipple reconstruction involve the use of local flaps and free grafts taken from the contralateral nipple or the labia minora [1, 2, 3]. A proven method of areolar reconstruction is to use a full-thickness skin graft taken from the upper–inner thigh or the groin. Tattooing can be used as an alternative method for areola reconstruction, eliminating the need for a donor site [4]. An effective dressing is the key to a successful reconstruction of the nipple–areola complex when a combined use of local flap and skin graft is considered. Several methods have been described for this purpose [5, 6]. We have developed a simple and practical dressing method following nipple–areola reconstruction by local flaps and full-thickness skin grafting. Simply, four 3-0 silk sutures are placed around the reconstructed nipple and eight 3-0 silk sutures are placed around the reconstructed areola. A 10 ml syringe is cut to a length of 1.5 cm and placed over the nipple with its base firmly located over the grafted area just around the nipple (Fig. 1). The sutures around the nipple are passed through the syringe and prepared for the tie-over stent. The standard bolus dressing using Vaseline-soaked gauze and cotton is applied over the skin graft and the stent is secured by tying the outer circle of sutures with those which have been passed through the syringe (Fig. 2). The stent is removed on postoperative day 4 and the graft viability is evaluated.

Cosmetic closure of pilonidal sinus defects with bilateral transpositional adipofascial flaps

Abstract The optimal treatment of the pilonidal sinus has not currently been defined. This study described the use of a modified bilateral transpositional adipofascial flap technique that effectively serves to flatten the deep natal cleft while keeping the scar limited to the intergluteal fold for good cosmesis. Between June 2007 and September 2011, 83 patients (61 men, 22 women) were included in the study. Duration of pilonidal sinus symptoms ranged from 1–15 (median 5) years; 15 patients had recurrent disease. Before the operation, perforating branches of the four pairs of lateral sacral arteries were identified with a Doppler audioscope. After complete excision of the sinus cavity and adequate undermining of the skin, bilateral adipofascial flaps were raised in order to realise a Yin-Yang pattern, with the lateral sacral artery perforators at the base of each flap. Complementary flaps were then transposed into the defect and inset to completely obliterate dead space. Skin was closed primarily in two layers. The median (range) defect size after total excision of the sinus cavity was 38 (19–60) cm2. All flaps survived. There was no wound infection or dehiscense. Median (range) follow-up was 26 (6–52) months. No recurrences were observed. Extensive scarring or asymmetry in the gluteal prominences was not observed. Transient paraesthesia over the flap donor region occurred in 14 cases (16%) and resolved completely within 6 months. The bilateral adipofascial transpositional flap method is an alternative to previously described treatment options in pilonidal sinus surgery. It is a safe, reliable, and easily applicable method, which provides cosmetically acceptable coverage of pilonidal sinus defects of moderate size.