Derya Özçelik

Soft tissue closure and plastic surgical aspects of large dorsal myelomeningocele defects (review of techniques)

The large myelomeningocele defects that cannot be closed reliably by simple skin undermining require a close cooperation between the neurosurgeon and the plastic surgeon. In this study, a 3-year review was undertaken of nine consecutive patients with a myelomeningocele defect treated in our hospital. The aim of the study was to analyze the size, location of myelomeningocele defects, features of the surrounding tissue, and type and results of the reconstruction method for skin closure. Of the nine patients, five were repaired within the first 48 h of life, two within the 1st month of life, and two were repaired within the 1st year of life. Of the nine patients, seven (78%) underwent repair with direct skin approximation by the Neurosurgical Service. For three patients (33%) with large lumbosacral meningomyelocele defects, including one patient who had failed direct skin approximation, the Plastic Surgery Service achieved the skin closure by bilateral paralumbar fasciocutaneous rotational flaps. Minimal area in the patients referred to the Plastic Surgery Service was 24 cm2 (range 24–48 cm2); patients having 18 cm2 or less skin defect were not referred for closure. In conclusion, fasciocutaneous rotational flaps provided tension-free, durable, innervated and well-vascularized skin coverage over the dural repair in all three referred patients, without using skin graft. Since myelomeningocele defects vary in size, shape, and location, no single procedure applies to all. Therefore, other reconstruction methods involving skin grafts, fasciocutaneous flaps, and musculocutaneous flaps are reviewed in this report.

Extensive Traction Alopecia Attributable to Ponytail Hairstyle and Its Treatment with Hair Transplantation

Alopecia is experienced by both men and women in all racial and ethnic populations. It can be nonscarring or scarring alopecia. Telogen effluvium, alopecia areata, traction chemical alopecia, and androgenetic alopecia are nonscarring alopecias, accounting for more than 90% of all causes of hair loss [8]. Other nonscarring alopecias include trichotillomania, tinea capitis, and hair shaft abnormalities. Scarring alopecia is caused by trauma, infection, discoid lupus erythematosus, or lichen planus [7]. Traction alopecia is traumatic hair loss secondary to the application of tensile forces to scalp hair. This condition can be classified as marginal or nonmarginal. In either case, the induced trauma, often the result of cultural, social, and cosmetic practices, is unintentional. Initially, the hair loss is reversible. However, permanent alopecia may result from chronic traction [5]. This report describes a patient with extensive traction alopecia located in temporal areas who received one session of hair transplantation with a satisfactory result.

Unilateral linear verrucous epidermal nevus of the face and the oral mucosa.

Verrucous epidermal nevi are linear hamartomas of epidermal structures that usually appear at birth or during infancy. They are usually found on the lower extremities and have resistance to treatment and risk of recurrence. They are rarely seen on the face and very rarely involve the oral mucosa. In the literature, only nine patients1–6 have been reported with the diagnosis of epidermal nevus involving oral mucosa since oral lesions were described by Brown and Gorlin7 in 1960. Here, we report a patient with an extensive verrucous epidermal nevus located on the face with intraoral extension.

Comparison of accuracy of three-dimensional spiral computed tomography, standard radiography, and direct measurements in evaluating facial fracture healing in a rat model.

Complex maxillofacial fractures demand a detailed understanding of the three-dimensional (3D) pattern of injury. Evaluation of the outcome of the facial fracture repair additionally requires optimal demonstration of fracture gap, bony union, fibrous callus or incorporation of fracture ends, presence of incomplete fusion, or pseudoarthrosis. Although 3D computed tomography (CT) is reliably used for the diagnosis of complex facial fractures, its value in facial fracture healing is unknown. An experimental study was conducted to determine the accuracy of 3D spiral CT scans in evaluating facial fracture healing during the early and late postoperative periods. In 10 adult Wistar Albino rats, a standardized bone defect (3 mm) was created within the mid portion of each zygomatic arch (n = 20). At 10 and 20 weeks postfracture, gap distance displayed by 3D CT and plane radiography (posteroanterior) were measured. At 20 weeks postfracture, intraoperative measurement was also performed. A comparison between 3D CT, radiography, and intraoperative findings was performed. At 10 weeks postfracture, the fracture sites displayed larger bone defects in imaging with 3D CT than with plane radiography. The difference between groups was statistically significant (P < 0.05). The mean defect size imaged by 3D CT was 0.91 ± 0.82 mm (standard deviation) and by plane radiography was 0.42 ± 0.16 mm. At 20 weeks postfracture, the mean defect size imaged by 3D CT was 0.56 ± 0.64 mm, and by plane radiography was 0.38 ± 0.22 mm. The difference between groups was not statistically significant (P > 0.05). The defect size imaged by both plane radiography and 3D CT was significantly less than the measurement obtained from the intraoperative assessment (P < 0.05). It was concluded that 3D CT has limited benefit in the detection of newly formed bone at week 10 and in the detection of fibrous callus, which can eventually give rise to the bony tissue. Plane radiography is more valid during the early postoperative period (week 10), because it can detect the fibrous callus and newly formed bone more precisely. Gap distance between fracture ends could be determined by 3D CT accurately at week 20, although there was a tendency, which was not statistically significant, to overestimate the amount of bone defect measured by 3D CT when compared with that of plane radiography.

The combined use of flaps based on subscapular vascular system for unilateral facial deformities

The correction of unilateral facial deformities presents a great challenge for the reconstructive plastic surgeon. Deficiencies of both the facial skeleton and the overlying soft tissue must be restored to achieve the optimal reconstructive result. Increasingly, a combination of two or more flaps is used for restoration of the composite defects. In the early 1980s, Harii et al.1 reported initial success in combining the latissimus dorsi myocutaneous flap and the serratus anterior muscle or myocutaneous flap using the microvascular technique. Since then, the transfer of multiple flaps based on a common, single vascular source has become a popular technique.

The Importance of the Trigeminal Cardiac Reflex in Rhinoplasty Surgery.

BackgroundTrigeminocardiac reflex (TCR) consists of bradycardia or asystole along with hypotension and apnea coinciding with stimulation of the trigeminal nerve. During rhinoplasty procedures, we noticed that local anesthetic solution (LAS) application to the columellar area results in bradycardia. We planned to conduct a randomized prospective study on 47 patients undergoing rhinoplasty to demonstrate the characteristics of TCR arising from the columella. MethodLocal anesthetic solution containing 2% prilocaine with 1:80,000 adrenaline was applied under standard general anesthesia protocol. In group 1 (study group, n = 24), 2 mL of LAS was applied to the columella. In group 2 (control group, n = 23), 2 mL of LAS was applied to the nasal dorsum. In group 3 (control group, n = 20), after LAS was applied to nasal dorsum in group 2, we waited for 10 minutes. Then, 2 mL of LAS was applied to the columella. Here, recordings were taken for the columella.Heart rate (HR) and blood pressure (BP) were recorded just before needle insertion (baseline level), at the time of needle insertion (NIT) to the columella or dorsum, and after the 1st, 5th, 10th, 30th, and 60th seconds. ResultsTransient bradycardia (≥20% drop in HR) was observed in 33% of the patients in group 1.Decrease in HR compared to the baseline level in group 1 was significantly greater than that of groups 2 and 3 at all times (P ⩽ 0.05).Systolic BP in NIT and in 60th second in group 1, only in NIT in group 2 was significantly lower than that of baseline levels (P ⩽ 0.05). ConclusionsWe concluded that stimulation of a sensory branch of the trigeminal nerve in the columellar area leads to TCR under general anesthesia by eliciting clinical hypotension with a drop in systolic BP and in HR of more than 20% compared to the baseline level.Knowing the existence of a certain TCR area will be helpful to the surgeon and anesthesiologist to exercise extra vigilance and to make continuous and meticulous monitoring of the electrocardiogram, HR, and BP during which the TCR may be precipitated such as local anesthetic infiltration to the columellar area in rhinoseptoplasty operations.

Repair of proboscis lateralis.

We report an 8-year-old girl presented with a proboscis on the right nasal nostril, right heminasal hypoplasia, hypertelorism, and cleft lip and palate on the other side. After repair of the cleft lip and palate and the hypertelorism, we succesfully reconstructed the heminose with a V-Y advancement flap containing the proboscis tube.

Adipose Tissue-Derived Stromal Vascular Fraction Increases Osteogenesis in an Experimental Design Zygomatic Bone Defect Model

Introduction: Facial bone defects are frequently encountered problems in clinical practice. Bone grafts, flaps, and alloplastic materials are often used in their treatment. This leads to donor site morbidity and prolongation of the operation. The authors have planned this study to examine whether adipose tissue derived stromal vascular fraction (SVF) has an osteogenic effect in the critical sized membranous bone defect of the zygomatic bone. Materials and Methods: Twenty male Wistar Albino rats were used. Bilateral zygomatic arches were opened with lateral incisions. A standard 3-mm bone defect was created bilaterally on the zygomatic arches of the rats. In the experiment side, the stem cell-rich SVF that was obtained by applying centrifugal process to the adipose tissue derived from the inguinal fat pad was injected into the site of the right zygomatic arch bone defect. In the control side, left zygomatic arch was left for secondary bone healing without any treatment after a 3-mm critical bone defect was created. In the postoperative 10th (n:5) and 20th weeks (n:13), the healing areas of bone defects were assessed by a 3-dimensional tomography, and then, the rats were sacrificed and bone healing was examined histologically. Results: There were no statistically significant differences on the 10th week results. At the 20th week new bone formation amount calculated from the 3-dimensional computed tomography results was significantly higher in the experiment side (P = 0.033). In the histological examination at the 20th week, there was significantly more callus formation in the experiment side (P = 0.0112). Discussion: Stem cells can increase the rate of bone healing by differentiating into certain tissues. It is predicted that adipose tissue-derived SVF rich with mesenchymal stem cells can increase bone healing in facial bone defects and this application could replace the use of bone grafts and flaps in clinical practice. As a result, it is concluded that adipose tissue-derived stem cells can potentiate osteogenesis and reduce the possibility of developing necrosis on the bone ends.