Cenk Demirdöver

Reconstruction of soft tissue defects following total knee arthroplasty

Soft tissue defects following total knee arthroplasty can represent serious problems for the patient and the surgeon. Perioperative soft tissue complications can result in loss of the prosthesis or limb. In this study, we present 17 cases with complex wounds following total knee arthroplasty who had surgery between May-1994 and July-2001. Patient-related factors, wound factors, surgical operation, secondary procedures, and duration of follow-up have been analysed for each patient. After local wound care and debridement, soft tissue defects have been covered with either a fasciocutaneous or gastrocnemius myocutaneous flap. All the knees (100%) have been salvaged although in 1 patient (6%) replacement of the prosthesis was necessary. In 5 patients (30%) secondary surgical procedures have been performed. Even though there is no consensus in the management of soft tissue defects following total knee arthroplasty, adequate wound care, including identification of infection, debridement, and early appropriate defect coverage should be the main points to consider.

Reverse temporalis muscle flap for the reconstruction of orbital exenteration defects.

Orbital exenteration is a surgical procedure that results in devastating functional and aesthetic losses. Many reconstructive techniques, ranging from spontaneous epithelialization to free flaps, have been described for orbital exenteration defects. The temporalis muscle flap is one of the most frequently used flaps to obliterate the orbital cavity, but only a small portion of the muscle can be used for this purpose because most of the muscle is used as the pedicle. The reverse temporalis muscle flap based on the superficial temporal vessels is a versatile flap by which the entire temporalis muscle can be elevated and carried to defects beyond the midline. The authors have used this flap for orbital reconstruction after exenteration in 6 patients with successful results. This flap enables placement of highly vascularized tissue that provides the reconstructive goals of primary healing, obliterates dead space with separation of the orbit from the nasal cavity or sinuses, provides the potential for early postoperative radiotherapy, and offers possible flaps that can be used in combination for complex, wide defects.

Treatment options in extravasation injury: an experimental study in rats.

Local skin necrosis after extravasation of doxorubicin hydrochloride (Adriamycin), a widely used chemotherapeutic agent, is a common problem in cancer patients. Even though several treatment options have been proposed for extravasation injury, there is still controversy regarding the management of such lesions. The aim of this study was to compare the efficacy of saline infiltration, vitamin C infiltration, suction technique, and early surgical excision as a treatment in a rat extravasation model. The authors planned their study in two stages. In stage 1, the lowest effective dose of doxorubicin at which a homogeneous skin necrosis was formed and the method of administration were investigated. Intradermal and subpannicular injections were made for six rats, using six different concentrations of doxorubicin (0.33, 0.5, 0.66, 1.0, 1.33, and 1.5 mg/ml). In stage 1, the intradermal injection produced homogeneous and uniform tissue necrosis. In stage 2, the efficacy of saline infiltration (group 1), vitamin C infiltration (group 2), suction (group 3), suction and saline washout (group 4), suction and vitamin C washout (group 5), and early surgical excision (group 6) was compared. The treatment options were applied 2 hours after doxorubicin injection. At the end of the seventh day, the presence and size of ulcers at the injection site were calculated. Fourteen days after injection, a histopathologic examination was performed for each treatment and control group. In groups 1 and 3, there was no statistically significant difference in the size of necrosis compared with the control groups. In groups 2, 4, and 5, the size of necrosis was smaller compared with the control groups, and this was statistically significant. Furthermore, in group 4 (suction and saline washout) and group 5 (suction and vitamin C washout), the calculated area of necrosis was smaller compared with other treatment groups, and this was statistically significant. The findings supported the assertion that suction and saline or vitamin C washout reduce necrotic tissue size in extravasation injury.

Necrotising fasciitis in the central part of the body: diagnosis, management and review of the literature

Necrotising fasciitis (NF) is characterised by rapidly spreading necrosis of the soft tissue and fascia. It is rare but can be fatal when not managed properly. The aim of this study is to evaluate the diagnosis, treatment and results such as mortality, morbidity and reconstructive options of NF localised in the central part of the body. The main goal is to emphasise upon the clinical symptoms for early diagnosis which is the most important factor in saving the lives of these patients. Between January 2000 and December 2010, 30 patients with NF localised in central parts of the body were treated. Six of the patients were female (20%) and the others were male (80%). The mean age was 54·03 years (ranged between 26 and 83 years). The average time from the onset of symptoms to diagnosis was 6 days, ranging from 2 to 11 days. The localisation of NF was perineum in 24 patients (80%); inguinal and thigh region in 5 patients (16·7); and back in 1 patient (3·3%). The hospitalisation time was varying between 17 and 32 days (mean 23 days). Six patients (20%) died and 24 patients (80%) survived. All non‐survivors had risk factors and secondary comorbidities such as immunosuppression, chronic cardiac failure, and diabetes with high glucose level. Survivors also underwent repeated debridement operation 2–4 times. Reconstructive procedures were split‐thickness skin graft (STSG) in eight patients (33·3%), fasciocutaneous flaps in four patients (16·6%), fasciocutaneous flap + STSG in six patients (25%), scrotal flap + STSG in two patients (6·6%), scrotal flap in two patients (6·6%) and musculocutaneous flap + STSG in one patient (3·3%). There was no major complication such as flap and graft loss, after reconstructive procedures. Early diagnosis of NF may be the lifesaving factor. Amuputation can save the patients life in the case of NF in the extremities; however, this is not an option for NF in central parts of the body. In these cases, when NF is suspected, early debridement of necrotic tissues should be performed. As soon as the infection and the spread of the necrosis are controlled, reconstruction should be considered.

Maximizing Breast Projection with Combined Free Nipple Graft Reduction Mammaplasty and Back-folded Dermaglandular Inferior Pedicle

Abstract:  Standard technique for free nipple reduction mammoplasty was described by Thorek in 1922 ( 1 ). In contrast to its effectiveness, late postoperative results included insufficient projection of the breast and the nipple–areola region. We describe a modification of this well recognized technique in order to increase central mound projection and improve nipple–areola projection by suturing the dermaglandular flap to the pectoralis major muscle by back‐folding the pedicle. Twenty macromastia patients were subjected to free‐nipple‐graft reduction mammoplasty in combination with inferior pedicled dermaglandular reduction mammaplasty of a total of 40 breasts with this technique between years 2000 and 2004. Preoperative planning for inferior pedicled dermaglandular flap was made using the “Wise” pattern for large breasts. The variation of the technique comes from using the back‐folded deepithelialized inferior pedicled dermaglandular flap for increasing the breast mound projection by fixating the demaglandular flap with absorbable sutures to the underlying pectoralis major muscle fascia and the costal cartilage pericondrium. By applying this technique, increased projection during the early preoperative and late postoperative periods are achieved, compared with patients who only underwent free‐nipple‐ graft reduction mammoplasty.

Anatomic and Functional Improvements Achieved by Rehabilitation in Zone II and Zone V Flexor Tendon Injuries

Objective: The aim of this study was to compare anatomic and functional improvements in zone II and zone V flexor tendon injuries and to determine the effect of injury level on disability. Design: Seventeen patients (53 digits) with zone V and 14 patients (25 digits) with repaired zone II flexor tendon injuries were enrolled in this study. All patients were treated with Modified Kleinert protocol and followed up for a median of 60 mos. The anatomic improvement was assessed by total active motion scoring system of the American Society for Surgery of the Hand. Quick Disability of the Arm, Shoulder, and Hand (Quick DASH) questionnaire and the grip strength value were used for the evaluation of functional improvement. Results: Two groups were similar with respect to age (P = 0.147), sex (P = 0.889), type of repair (P = 0.453), and follow-up period (P = 0.499). According to total active motion scoring system, good to excellent results (75%-100% of the normal total active motion value) were achieved in 52% of the digits with zone II and 83% of digits with zone V flexor tendon injuries (P = 0.004). The recovery in the grip strength, in comparison with the uninjured hand, has been found to be 71% and 53% in zone II and zone V injuries, respectively (P = 0.112). There was no difference between Quick DASH index scores of two groups (P = 0.721). The grip strength percentage (r = −0.435; P = 0.014) and total active motion recovery results (r = −0.541; P = 0.002) of the patients were moderately correlated with Quick DASH scores. Conclusions: Early passive mobilization in patients with zone V injuries resulted in higher percentage of good to excellent results when compared with zone II injuries. However, this does not translate into recovery in grip strength and disability. This study suggests that although the level of the injury is an important factor for the anatomic improvement, it may not be the predictor of functional improvement.

Delayed prefabricated arterial composite venous flaps: an experimental study in rabbits.

&NA; Prefabrication of composite arteriovenous flaps with implantation of an autologous graft (cartilage) or an alloplastic material (porous polyethylene) was studied in 40 rabbits. Abdominal flaps based on bilateral epigastric pedicles were elevated. An ear cartilage graft or a porous polyethylene implant was inserted under the flap. Two weeks after the operation, 10 flaps with cartilage graft and 10 flaps with porous polyethylene were raised, converted to arteriovenous flaps, and resutured in place in the experimental groups. In the other 20 rabbits of the control groups, the flaps (10 with cartilage graft and 10 with porous polyethylene) were raised and resutured in place as conventional axial flaps. At the end of the second and fourth week postoperatively, samples were obtained from the flap tissues (including a part of the graft or implantation material) and were prepared for histologic examination in all rabbits. The viable areas of all flaps were assessed at the end of fourth week after the second operation. The mean survival rates were 99.4%, 99.7%, 99.5%, and 99.8% in the arteriovenous and control flaps prefabricated with cartilage graft and the arteriovenous and control flaps prefabricated with porous polyethylene respectively. The features of wound healing in the experimental and control groups were similar. The study showed that arteriovenous perfusion can nourish a prefabricated flap containing an implanted material (autologous or alloplastic) and these 2‐week delayed composite flaps have a similar survival rate to delayed prefabricated conventional axial flaps. Karataş Ö, Atabey A, Demirdöver C, Barutçu A. Delayed prefabricated arterialized composite venous flaps: an experimental study in rabbits. Ann Plast Surg 2000;44:44‐52

Isolated fibrous dysplasia of the zygomatic bone.

Fibrous dysplasia is a nonneoplastic, hamartomatous, developmental disease of the bone of obscure etiology. The disease is generally presented as a continuously growing, painless mass at late childhood. It is mostly seen in the maxilla and the mandible in facial skeleton. Involvement of the zygomatic bone is far rarer. Fibrous dysplasia of the zygomatic bone may cause orbital dystopia, diplopia, proptosis, loss of visual acuity, swelling, mass formation, or facial asymmetry. We present 2 cases of fibrous dysplasia with isolated zygomatic bone involvement.

Keloid formation after circumcision and its treatment

Circumcision is performed in many communities around the world for either medical, ethnic, or religious issues. It is a safe procedure when it is performed by a fully trained surgeon. However, complications such as bleeding, infection, diminished penile sensation, urethral injury and amputation of the glans are occasionally seen. Keloid is the result of excessive deposition of collagen in the dermis and subcutaneous tissues. It usually develops at the site of trauma or surgical injuries. Keloid formation on the penis is a very rare condition. In this study, we present a case of keloid formation after circumcision and review the related literature.

Reduction mammaplasty for phyllodes tumor causing asymmetry in an adolescent female.

A n 11-year-old girl was admitted to another hospital with breast asymmetry 2 months earlier. Incisional biopsy was performed and the pathologic evaluation was reported as a benign phyllodes tumor. She was referred to our clinic for further examination and treatment. On clinical examination, we palpated a well-circumscribed, mobile, rubbery mass, 5 cm × 6 cm × 9 cm, that caused asymmetry in her breast (Fig. 1). After performing routine blood tests and other analyses, surgery was planned to remove the mass and restore symmetry in the same operation. The mass was reached via an appropriate incision with a superior pedicle reduction mammaplasty technique. The mass was removed, achieving a 1.5–2 cm margin in all directions. Symmetry was restored by moving the nippleareola complex to its new location with a superior pedicle technique (Fig. 2). The patient had no complications in the postoperative period and the pathologic evaluation of the specimen was reported as a benign phyllodes tumor (Fig. 3). At the end of the 36-month follow-up of the patient, no recurrence had been observed. DISCUSSION