Cengiz Acikel

Defining vascular supply and territory of thinned perforator flaps: part I. Anterolateral thigh perforator flap.

Background: The anterolateral thigh perforator flap is increasingly being used for trauma and reconstructive surgical cases. With the thinned flap design, greater survivability and a decrease in donor-site morbidity are observed. To increase our knowledge of the vascular territories in these flaps, an anatomic study was performed to determine pedicle number, location, and diameter; accompanying veins; vascular territory; and where surgical incisions can be made safely during thinning, as opposed to the “danger zone.” Methods: Thirteen anterolateral thigh perforator flaps were harvested from seven adult cadavers. The largest perforator arteries were cannulated, and flaps were thinned to a thickness of 6 to 8 mm, with a 2.5-cm radius from the perforator retained. Vascular territories were quantified before and after thinning by nonradiographic and radiographic methods. A series of dyes were injected: red dye for skin (photography) followed by Omnipaque for the whole flap (radiography) before thinning, and blue dye for skin (photography) and lead oxide for the whole flap (radiography) after thinning. Pedicle locations were determined by ratios of anatomical landmarks. Danger zone measurements were derived at specific thicknesses using lateral radiographs of each flap. Results: In anterolateral thigh perforator flaps, the mean perforator artery diameter at the fascia level was 1.00 ± 0.08 mm (range, 0.84 to 1.11 mm) and the mean number of perforator arteries was 1.69 ± 1.03 (±SD). Perforator pedicles were located near the midpoint of the line between the anterior superior iliac spine and the lateral aspect of the patella in the vertical axis. The mean vascular territories were 256 ± 52.5 cm2 (photography) and 351 ± 72.8 cm2 (radiography) in unthinned flaps and 211 ± 65.7 cm2 (photography) and 289 ± 106.6 cm2 (radiography) in thinned flaps. Differences in overall vascular territories after thinning were 83.3 percent (photography) and 81.8 percent (radiography) compared with unthinned flaps. Four respective vascular territory maps were drawn showing surgical territories using percentile confidence intervals (98th and 90th) and averages. From the skin at thicknesses of 4, 6, and 8 mm, the 98th percentile danger zones were 33 to 37 mm (proximal to distal), 30 to 35 mm, and 27 to 31 mm from the pedicle in the vertical axis, respectively; in the horizontal axis, they were 30 to 34 mm (medial to lateral), 28 to 31 mm, and 25 to 29 mm. Conclusions: These data define anterolateral thigh perforator flap pedicle location, number, and diameter before harvesting, surgical danger zones during thinning, and vascular territories after thinning. The authors’ guidelines provide surgeons with anatomical vascular territory maps to design and harvest specific flaps for optimal results.

Various applications of the medial plantar flap to cover the defects of the plantar foot, posterior heel, and ankle.

The medial plantar fasciocutaneous flap provides structurally similar tissue to plantar foot, posterior heel, and ankle defects with its thick glabrous plantar skin, shock-absorbing fibrofatty subcutaneous tissue, and plantar fascia. During the past 4 years, 24 patients (20 men, 4 women) with skin and soft-tissue defects over the plantar foot, posterior heel, or ankle were treated. They ranged in age from 20 to 42 years (mean, 24 y). The medial plantar flap was transposed to the defects in four different ways: proximally pedicled sensorial island flaps (N = 18), reverse-flow island flaps (N = 2), free flaps (N = 2), and cross-foot flaps (N = 2). Flap size varied from a width of 2 to 5.5 cm and a length of 5 to 7.5 cm. The follow-up period ranged from 2 to 18 months (mean, 9 mo). Partial flap loss was observed in one free flap and one reverse-flow island flap. Partial skin graft lost in the donor site required regrafting in one patient. Durable, sensate coverage of the defects was achieved in all patients.

Treatment of burn scar depigmentation by carbon dioxide laser-assisted dermabrasion and thin skin grafting

Permanent depigmentation occasionally develops after deep partial-thickness and full-thickness burn injuries, which heal by secondary intention. This problem can be solved by dermabrasion and thin split-thickness skin grafting. However, mechanical dermabrasion is a bloody procedure that risks exposing medical professionals to infectious diseases transmitted by blood products, and it is difficult to assess the extent of tissue ablation. In this study, dermabrasion of depigmented burn scar area was performed by using flash-scanned carbon dioxide laser treatment, followed by thin split-thickness skin grafting. This method was applied to 13 patients on whom burn scar depigmentation sites were located as follows: two in the facial area, four on the trunk, and seven on the extremities. Skin graft take was excellent in all patients except for one. The follow-up period for these patients ranged from 1 to 12 months, with an average of 8 months. Repigmentation appeared soon after grafting, and no depigmentation occurred again in the treated areas. In conclusion, depigmented burn scar areas can be dermabraded in a short time; depth of tissue ablation can be well controlled; and a bloodless and smooth raw surface can be created by using a flash-scanned carbon dioxide laser. These raw surfaces sustain thin skin grafts well. (Plast. Reconstr. Surg. 105: 1973, 2000.)

Management of maxillofacial problems in self-inflicted rifle wounds

Severe gunshot wounds to the face, produced by high-velocity rifles or shotgun blasts, present a formidable challenge to reconstructive surgeons. In this study, the results of 14 cases with gunshot wounded faces caused by fire from rifles are presented, and the principles of the management of those victims were determined. These patients had attempted to commit suicide and placed the muzzles of the rifles beneath their chins. The ages of the patients ranged from 20 to 24 years, with a mean age of 22 years. These wounds were caused by close-range gunshots (<10 cm), and the missiles had high velocity (more than 800 m/second). All patients had wounds in their submental triangle areas. The exit sites of the missiles differed among patients. All exit wounds were in the angle limited by the deviation from the gun-barrel axis. After clinical and radiologic evaluation and conservative debridement of all devitalized tissues, the fractures were reduced and stabilized appropriately. Large bony defects were treated by bone grafting, and all soft tissue lesions were closed in layers. The entrance and exit sites were covered primarily after thorough debridement except one case whose defect was reconstructed with bilateral sternocleidomastoid (SCM) flaps, one for submental skin and the other for the mouth floor. Intraoral soft tissues were then repaired by primary closure, tongue flaps, or SCM flaps in case they were necessary. Free tissue transfers were not required for treatment of secondary soft-tissue problems. Resolution of tissue edema, softening of scars in time, and insertion of bone graft may improve the deformity significantly. The initial anatomic reconstruction of the existing bone skeleton and the maximal use of regional tissue for cutaneous reconstruction provide an esthetic appearance that can never be duplicated by secondary reconstruction.

Treatment of severely contracted fingers with combined use of cross-finger and side finger transposition flaps.

Background: In the present study, the authors combined use of the cross-finger flap and the side-finger transposition flap to cover the skin and soft-tissue defect created by contracture release of severely contracted fingers. Methods: Eight patients having Stern type III flexion contractures of the proximal interphalangeal joints were included. The cause of injury was burn in six patients and trauma in two patients. The average follow-up period was 11.6 months. Results: All operations were successful. Lack of extension of the proximal interphalangeal joint was improved by approximately 81.2 degrees for all digits. Conclusion: Stern type III contracture of the proximal interphalangeal joint can be released by transverse incision and ample resection of scarred tissue, and the resulting palmar skin defect that cannot be covered by using the fingers own flaps or cross-finger flap can be covered by combined use of cross-finger and side-finger transposition flaps.

Carbon dioxide laser resurfacing and thin skin grafting in the treatment of "stable and recalcitrant" vitiligo.

Various surgical methods have been used in the treatment of small stable vitiliginous areas, but there is no established surgical approach for larger vitiligo areas and therapy-resistant anatomic sites, such as the hands. Two years ago, we successfully treated large burn scar depigmentation areas at different anatomic sites using carbon dioxide laser resurfacing and thin (0.2 to 0.3 mm) skin grafting. The purpose of this study was to investigate the effectiveness of our method in treating large, stable, and recalcitrant vitiligo areas. Thirteen anatomic sites of seven male patients, whose ages ranged from 20 to 22 years, were treated. The locations of the treated areas were as follows: seven areas on the dorsum of the hands, two areas on the forearms, two areas in the pretibial region, one area on the lateral thigh, and one area in the presternal region. The surface area of treated vitiligo sites ranged from 0.5 to 6 percent of total body surface area (mean, 2.5 percent). Skin graft take was excellent in all patients except for one. The follow-up period for these patients ranged from 6 to 18 months, with an average follow-up period of 14 months. Early and complete repigmentation was achieved and the color match was good or excellent in all patients. No depigmentation occurred again in the treated areas or graft donor sites. In conclusion, with careful patient selection and delicate surgical technique, our method was effective in treating large areas of vitiligo over the extremities and dorsum of hands, which were refractory to other therapies and could not be hidden.

Defining Vascular Supply and Territory of Thinned Perforator Flaps: Part Ii. Superior Gluteal Artery Perforator Flap

Background: Superior gluteal artery perforator flaps are surgical options in breast and pressure sore reconstructions. Based on the recipient site, primary thinning of these flaps may be necessary for final optimal contour. As the thinning of a superior gluteal artery perforator flap should be based on the knowledge of perforator vascular territories to prevent vascular compromise, the authors performed an anatomical study to determine the number, location, and diameter of the perforators present in the superior gluteal artery perforator flap. Accompanying veins and acceptable locations for surgical incisions were also determined. Methods: Fourteen superior gluteal artery perforator flaps were harvested from seven cadavers. Perforator flaps were thinned to 8 to 15 mm, except for a 2.5-cm radius around the dissected perforator. Vascular territory areas were quantified before and after thinning by photographic and radiographic methods, and respective vascular territory maps were constructed. Surgical incision “danger zones” of vertical and horizontal axes were determined at specific depths (relative to the skin surface) for each flap. Danger zone measurements were determined with an automatic three-dimensional vascular tree construction using computed tomographic images and several modeling algorithms. Results: Mean perforator artery diameter and number at the fascia level were 0.91 ± 0.07 mm and 2.86 ± 0.77 (mean ± SD), respectively. Perforator pedicles were located midway between the posterior superior iliac spine and the greater trochanter. After thinning, skin surface and whole flap vascular territories were reduced 80.9 percent (photographic) and 76.9 percent (radiographic), respectively, compared with unthinned vascular territory areas. From the skin at 4-, 6-, and 8-mm thicknesses, elliptical danger zones (two vertical segments and two horizontal segments) had overall vertical segment axis length ranges from the pedicles of 59 to 66 mm, 51 to 57 mm, and 49 to 51 mm, respectively. Horizontal axis segment length ranges were 61 to 76 mm, 61 to 66 mm, and 60 to 57 mm for 4-, 6-, and 8-mm skin thicknesses, respectively. Conclusions: The superior gluteal artery perforator flap provides an excellent blood supply to adipose tissue but may be compromised when aggressively thinned. Surgeons may design and harvest partially thinned superior gluteal artery perforator flaps based on the anatomical vascular territory maps provided by this study.

Y-shape hard palate mucoperiosteal graft and V-Y advancement flap in the reconstruction of a combined defect involving lateral canthus and upper and lower eyelids.

Curative ablation of a baso-squamous cell carcinoma of lateral cantus and both eyelids resulted in a complex full-thickness defect of upper and lower eyelids, lateral canthal area, and lateral canthal tendon. The reconstruction of the defect was performed in a single stage using a Y-shape hard palate mucoperiosteal graft and a Y-shape skin flap advanced from the temporal side of the defect on its subcutaneous pedicle. The graft donor site healed spontaneously and the flap donor site was closed primarily. A durable and stable coverage of the defect could be achieved with minimal donor site morbidity.

Nonsurgical delay of dorsal rat cutaneous flap using a long-pulsed 1064-nm Nd:YAG laser with a contact cooling device.

Background: This study evaluated the efficiency of a long-pulsed neodymium:yttrium-aluminum-garnet laser, operating at 1064 nm and equipped with a contact cooling device, in the delay of a caudally based dorsal rat skin flap (10 × 3 cm). This laser has deeper tissue penetration and has not been used for this purpose before. Methods: Twelve male Sprague-Dawley rats were used in each of six groups. The delay effects of three different laser treatment patterns (only longitudinal borders, cephalic and longitudinal borders, and entire surface of the 10 × 3-cm flap) were compared with an acute untreated control flap as well as two surgical delay methods (incision of longitudinal borders and incision of longitudinal borders plus flap undermining). The laser effects on the cutaneous vasculature and perfusion were assessed by intravenous fluorescein injection, histologic study, microangiography, and in vivo real-time video monitoring. Results: Selective thermocoagulation of subdermal vessels was achieved using a 6-mm spot, 140-J/cm2 fluence, and 40-msec pulse width. In the cephalic and longitudinal borders laser-treated group, a delay effect was achieved. The maximum delay effect was achieved by the surgical delay group that used the method of incision of the longitudinal borders plus flap undermining. Laser treatment of only the longitudinal borders did not improve flap survival, whereas treatment of the entire flap surface significantly reduced flap survival. Conclusion: Nonsurgical delay of a dorsal rat cutaneous flap is possible by selective occlusion of the subdermal plexus at the longitudinal and cephalic borders of the planned flap using a long-pulsed 1064-nm neodymium:yttrium-aluminum-garnet laser equipped with a contact cooling device.

Serum lactate dehydrogenase levels significantly correlate with radiological extent of disease and spirometric values in patients with silicosis due to denim sandblasting.

Abstract Background: The aim of the present study was to investigate serum lactate dehydrogenase (LD) levels in patients with silicosis due to denim sandblasting (SDDS) and also to investigate possible correlations between serum LD levels and the degree of radiological extent of disease (RED) and pulmonary function tests. Methods: Forty-four males with SDDS and 32 healthy male subjects were included in the study. Patients and healthy controls were compared for serum LD levels. Correlations between serum LD levels, RED and spirometric values were investigated. Results: Patients with SDDS had significantly higher serum LD levels than healthy controls. Patients with complicated SDDS had significantly higher serum LD levels than patients with simple SDDS. Significant correlations were found between serum LD levels and RED values. Significant correlations were found between serum LD levels and spirometric parameters. Conclusions: High serum LD levels might be considered as a marker of pulmonary parenchymal involvement in patients with SDDS. This study also suggests that the increase in serum LD levels might be closely related to the degree of pulmonary involvement in SDDS patients.