Can Cinar

Soft-tissue reconstruction of sole and heel defects with free tissue transfers.

&NA; Reconstruction of the weight‐bearing surface of the foot is a challenging problem for the reconstructive surgeon. Because local tissues are not usually available for reconstruction, distant tissue transfers are often necessary. The authors report 20 patients with sole and heel defects that were reconstructed with free flaps. Two patients had bilateral reconstruction. Three patients were younger than 10 years. Etiological causes were burn scar (N = 7), trauma (N = 7), chronic wound (N = 3), and tumor resection (N = 5). All defects were located at a weight‐bearing area. Gracilis muscle (N = 11), neurosensorial radial forearm (N = 7), latissimus dorsi muscle (N = 2), rectus abdominis muscle (N = 1), and posterolateral thigh flaps (N = 1) were used for reconstruction. Muscle flaps were preferred for the deep and irregular defects or chronic, open infected wounds. All flaps survived except for one total and two partial complications of necrosis. Recurrence of ulceration was observed in 1 patient with spinal cord trauma. The mean follow‐up period was 33.7 months (range, 1‐84 months). Patients were evaluated by direct gait observation, footprints, pedograms, and the Semmes‐Weinstein monofilament test. All patients returned to normal daily activity with individual gait patterns. Functional outcomes of both muscle and fasciocutaneous flaps were satisfactory. Presence of deep sensation, preservation of musculoskeletal integrity, and patient compliance are the main factors for durability of reconstruction. Yücel A, Ŝenyuva C, Aydin Y, Çinar C, Güzel Z. Soft‐tissue reconstruction of sole and heel defects with free tissue transfers. Ann Plast Surg 2000;44:259‐269

Promoting primary healing after ray amputations in the diabetic foot: the plantar dermo-fat pad flap.

Background: Amputation of the toe at the level of the distal metatarsal head (ray amputation) is a common surgical procedure in diabetic foot ulcers. The aim of this study was to introduce a new technique promoting primary healing by minimizing the dead space with the plantar dermo-fat pad flap after central ray amputation in diabetic foot ulcers. Methods: Thirty-eight patients who had undergone central ray amputation and closure with the plantar dermo-fat pad flap between 1996 and 2003 were incorporated into the study. Results: The mean follow-up period was 3.56 years. Single and multiple middle toe amputations were performed in 33 and five cases, respectively. In 14 cases with acute infection, split-thickness skin graft was used with the plantar dermo-fat pad flap to close the defect on the foot dorsum. Healing time was uneventful in all patients except three (8 percent), who were healed with local wound care. No patient showed signs of ulceration at the operative site during the follow-up. The mean time to total healing was 40.31 ± 34.56 days. Conclusions: The plantar dermo-fat pad flap promotes primary wound healing after central ray amputation in diabetic foot ulcers by filling the dead space. The osteotomy to the base of the remaining adjacent metatarsal base in an effort to close the defect can be avoided by using the plantar dermo-fat pad flap; thus, undesirable angulation of the remaining parts of the foot can be eliminated. The plantar dermo-fat pad flap also supports the weak articular capsule of the adjacent metatarsophalangeal joints while covering the amputated metatarsal end. The thick, healthy plantar soft tissue advanced up to the width of the deepithelialized area reestablishes a good, tough plantar surface which—in association with the pad effect of the flap—decreases the recurrence rates and provides comfortable ambulation.

Malignant tumors requiring maxillectomy.

&NA; Seventy cases with malignant tumors requiring maxillary resection in the past 10 years were reviewed, retrospectively. The primary site of tumor was adjacent skin in 53%, maxillary sinus or maxilla in 20%, palate and alveolar arch in 13%, lip and buccal mucosa in 13%, and mandible in 1% of the cases. The most common histopathological diagnoses was squamous cell carcinoma (54%), followed by basal cell carcinoma (20%). Most of the patients had advanced tumors, either neglected or recurred. Orbital exenteration was performed in 28 cases, mandibulectomy in six cases, combined craniofacial resection in seven cases, and radical neck dissection in 18 cases. Major skin loss was present in majority of the patients. Postsurgical defects were reconstructed with pedicled flaps in 37 cases and free flaps in 12 cases. Lining of the maxillary sinus defects was provided with split‐thickness skin grafts. Patients with palatal defects were encouraged to use prosthetic obturators. Postoperative radiotherapy was performed in 32 patients and combined radiotherapy and chemotherapy in 12 patients. Communication could be established with only 52 patients. Sixty‐three percent of them have survived without recurrence and distant metastasis. Resection of the tumor with free surgical margins and appropriate evaluation of the surgical defect for the most suitable reconstruction are the mainstays of treatment of the midfacial tumors.

The Epidemiology of Foot Wounds in Patients with Diabetes: A Description of 600 Consecutive Patients in Turkey

Epidemiological studies describing demographic, clinical, and surgical characteristics of diabetic foot wounds are lacking in Turkey. To further describe the epidemiology of diabetic foot wounds in Turkey, we developed an evaluation form and performed a retrospective cohort study that entailed 600 diabetic patients who were admitted to the hospital for treatment of their foot wound(s). The mean age of the cohort was 62.3 ± 10.3 (range 23-92) years, and their mean duration of diabetes was 17.4 ± 7.4 years. Males accounted for 68.17% of the cohort, and 96.83% of the cohort had type 2 diabetes. Prevalences for lower extremity arterial pulses and peripheral neuropathy, as well as the location, depth, microbiology, and surgical treatment of the pedal wounds are also presented. In conclusion, diabetic foot wounds are common in Turkey, and the morbidity associated with these lesions is generally substantial. Although our investigation aimed primarily at describing risk factors associated with diabetic foot wounds, we believe that the findings of this investigation can be used in the development of prospective cohort studies and randomized controlled trials that focus on foot wounds in diabetic patients in Turkey, and may be useful to investigators in other parts of the world.

The Effect of Epidural Anesthesia on Muscle Flap Tolerance to Venous Ischemia

Background: Venous ischemia is a major cause of failure after free tissue transfers and replantations. The combination of general and epidural anesthesia leads to vasodilatation and improves tissue perfusion. Postoperative pain relief and sympathetic blockage are additional benefits of epidural anesthesia. The purpose of this study was to determine whether epidural anesthesia has benefits on microcirculation and neutrophil functions in muscle flaps subjected to venous ischemia. Method: Thirty Sprague-Dawley rats were divided into three groups: group I, general anesthesia; group II, spinal anesthesia; and group III, epidural anesthesia. Cremaster flaps were prepared, postcapillary venules were selected under intravital videomicroscopy, and flaps were subjected to venous ischemia. Images were recorded from preselected postcapillary venules before venous ischemia (baseline) and following reperfusion. Neutrophil rolling and adhesion, functional capillary density, and diameters of postcapillary venules were evaluated. Results: The increase in rolling neutrophils in group III was significantly lower than in groups I and II at 60 and 120 minutes. Change of adherent neutrophils in group III was significantly lower than in groups I and II at 15, 60 and 120 minutes. There was significantly more reduction in inner diameter of postcapillary venules in groups I and II compared with group III. Functional capillary density in groups I and II was significantly lower than in group III. Conclusion: Epidural anesthesia regulated neutrophil functions, salvaged functional capillaries, and prevented vasoconstriction of postcapillary venules in cremaster muscle flaps subjected to venous ischemia. Spinal and general anesthesia, however, were found to be ineffective in improving microcirculation of muscle flaps subjected to venous ischemia.

Sclerotherapy to a large cervicofacial vascular malformation: a case report with 24 years' follow-up.

Large craniofacial venous malformations frequently cause significant cosmetic and functional problems. Treatment of the lesions early in life helps to avoid these problems. We present a case of a large cervicofacial venous malformation.

A reliable surgical approach for the two-staged amputation in unsalvageable limb and life threatening acute progressive diabetic foot infections: Tibiotalar disarticulation with vertical crural incisions and secondary transtibial amputation

BACKGROUND If all efforts to treat acute progressive diabetic foot infection remain insufficient, the decision of major amputation should be undertaken. For this purpose, guillotine amputation is usually performed first. However, guillotine amputation below the knee level may cause the corresponding infection to spread to preserved anatomical spaces. METHOD First stage of our procedure consists of tibiotalar disarticulation and vertical incisions performed throughout the lower leg to remove the septic foot and drain the compartments. During the interval period, appropriate antibiotherapy and wound care are applied. After the interval period, definitive transtibial amputation is performed in the second stage. RESULTS Fifty-nine percent of the 62 transtibial amputations were healed completely. Failure developed in 3 cases which required opening of the amputation stump. In one patient, revision amputation at a higher transtibial level was done. Infection and necrosis reached to the knee joint in the other two patients and transfemoral amputation became the only treatment option for these 2 cases. CONCLUSION Tibiotalar disarticulation with vertical lower leg incisions as a first stage of two-stage transtibial amputation is a safe and reliable method. It reduces the risk of unnecessary tissue sacrifice and failure rate of the secondary transtibial amputation.

Laser Lipolysis Without Suction: Reality or Myth?

BACKGROUND AND OBJECTIVE Liposuction is one of the most frequently performed aesthetic surgical procedures. Laser- and ultrasound-based systems have become especially popular in recent years, including laser lipolysis, which has a number of advantages over classic liposuction. Some researchers contend that the aspiration step is not necessary. Herein, we report a case that highlights the negative consequences when the basic surgical rule of not leaving any necrotic tissue is not followed. MATERIALS AND METHODS We report the case of a 50-year-old man who presented with a 15 cm mass in the right lower quadrant, located immediately subcutaneously, passing the midline infraumbilically, tender to touch, and with beginnings of abscess formation, who underwent laser lipolysis. The subcutaneous necrotic fat was removed with a skin island en bloc. No postoperative complications occurred and the patient was problem free 6 months post-surgery. RESULTS In the surgical literature, most studies on fat necrosis have focused on fat necrosis in the breast. Fat necrosis is usually a gradual process that is noticed by the patient or physician as a mass. Radiologically, it can imitate cancer, especially in breast tissue. Complications from fat necrosis are primarily linked to the amount of necrosis. Any amount of necrosis above the bodys resorption capacity will lead the body into attempting self-limitation, with consequences to both the physical and psychological health of the patient. CONCLUSIONS We believe that claiming that no aspiration is required after laser lipolysis, without the necessary studies, has no scientific basis.

Re: A benign Schwannoma of the digital nerve distal to the proximal interphalangeal joint

A 38 year-old labourer sustained distal radius and midshaft ulnar fractures after a fall. He was treated by open reduction and internal fixation of both bones elsewhere. The ulna was fixed with a dynamic compression plate and the distal radius with a fixed-angle volar plate (Hand Innovations, Miami, FL, USA). He presented to our clinic 2 2 years after surgery complaining of prominent painful hardware and wanted both plates removed. On physical examination, the patient was found to have tenderness to palpation over both plates. Under anaesthesia, the ulnar plate was exposed and removed without difficulty. The radial plate was exposed and the two proximal 3.5mm shaft screws removed with a standard large fragment screwdriver, without difficulty. However, removing the four distal fixed-angle locking 2.5mm partially threaded screws proved to be extremely difficult. One screw was removed with a power screwdriver after a few failed manual attempts. One screw could only be unscrewed by 2mm, after which it became lodged and would not loosen further. The other two screws were half removed until the point when the trailing threads began to engage the volar radial cortex, after which they also became lodged. Multiple tools were used in the attempted removal of the three screws to no avail, and the screws eventually became stripped. A last attempt was made to divide the screws with an osteotome between the plate and the radius, but this also proved ineffective and removal of the plate was abandoned. A Midas Rex metalcutting attachment (Medtronic, Minneapolis, MN, USA) was used to remove the prominent parts of the screws flush with the plate and to smooth the rough edges of the plate. The plate and buried portions of three screws were left in situ. Postoperative recovery was uneventful and, 6 months after surgery, he had recovered the same (functional) range of motion of the wrist and digital joints as pre-operatively, but with slight volar wrist pain. Volar plating of distal radial fractures has emerged as a popular method of treatment, and advocates of this technique of plating favour it over the dorsal approach as the fixed-angle device is less prominent and causes less tendon irritation or risk of tendon rupture (Smith and Henry, 2005). However, with increasing use, complications have also surfaced. Rupture of the flexor pollicis longus tendon is of most concern and has led some to support routine removal of volar plates (Drobetz and Kutscha-Lissberg, 2003). The exact reason why the screws could not be removed in this case is unclear. It is possible that a contributing factor was healing new bone formation under the plate. Perhaps because of the extended time since primary surgery (2 2 years), a new bone overgrew both the leading and trailing titanium screw threads. The partially threaded screws may have been responsible. It was possible to back out these relatively weak screw threads to the point where it seemed that the trailing threads were engaging the dense near cortex. Overgrowth of the cortex and/or inability of the partially threaded screws to back out through this cortex then prevented the screws from being retrieved. The purpose of this communication was not to dissuade colleagues from using volar plates, but to make the surgical community aware of this complication. Removal of these plates should be done only if absolutely necessary and with awareness of the possibility of difficulty in retrieving the distal screws.

Mandibular metastases of papillary thyroid carcinoma treated by hemimandibulectomy and costochondral rib graft.

Summary: Papillary thyroid carcinoma (PTC) is the most common and well-differentiated cancer of the thyroid. Unlike most cancers, spread to local lymph node does not worsen the survival rate of PTC, and complete resection of the metastases seems to be important and may have favorable effects on the prognosis. A 33-year-old woman was referred to our clinic with a mass involving the right angulus mandible. Incisional biopsy of the mass diagnosed follicular variant of papillary thyroid carcinoma. Right hemimandibulectomy was performed and reconstructed with costochondral rib graft. The patient survived for 5 years after the hemimandibulectomy. Metastases to the oral cavity indicate a grave prognosis, but PTC has relatively indolent biological behavior; long-term survival is usually possible even in patients with metastatic disease.