Ercan Karacaoglu

Implant-based breast reconstruction with allograft.

Background: Reconstructive breast surgeons often prefer autologous tissue for those patients who can tolerate it. However, reconstruction with implants is technically easier, quicker, less traumatic, and less costly. Nevertheless, inherent problems associated with implants present some limitations to their use in reconstruction. In this study, a multipurpose application of allogenic dermal grafts to solve the problems seen in immediate breast reconstruction with implants was examined. Methods: After skin-sparing mastectomy, a subpectoral pocket is created for the implant. After the origins of the pectoralis major muscle are released, AlloDerm is sewn to the lower pole of the released muscle. Grafts are tailored according to the dimensions of the defect. AlloDerm, an allogenic dermal graft, is fixed to the pectoralis major superiorly, to the chest wall inferiorly and inferomedially, and to the serratus anterior flap laterally. A postoperative adjustable implant is placed into the pocket that has bene created. Result: Allografts were used to reconstruct 30 breasts in 24 patients immediately after skin- or nipple-sparing mastectomy. There was no complication related to simultaneous allograft application. No rippling, symmastia, or bottoming-out deformity was seen. Conclusions: Breast reconstruction with implant and AlloDerm enables the surgeon to create a submuscular pocket large enough to place a fully inflated breast implant. Interposition of a lower-pole internal sling, to increase the capacity of the pectoralis major pocket while providing immediate ability to achieve full or subtotal prosthetic fill and optimal aesthetic breast contouring and to maintain thicker muscle coverage in the upper and medial pole areas and stronger lower pole support, would obviate many of the current disadvantages to implant reconstruction.

Nerve regeneration through side-to-side neurorrhaphy sites in a rat model : A new concept in peripheral nerve surgery

Despite great improvement and refinements in nerve repair techniques, there were still problems in repair of peripheral nerve injuries for which proximal stumps were not available. In these circumstances for which classic end-to-end neurorrhaphy was impossible, new treatment modalities, benefiting by an adjacent healthy nerve, have been under investigation to overcome this problem. Therefore, end-to-side nerve repair with its modifications came to view and axonal passages through this site were shown. Moreover, the results were unsatisfactory or necessitating sacrifice of another healthy nerve. Three groups, containing 10 rats each, were included in the study. First was the control group, with end-to-end repair of the peroneal nerve. Second was the end-to-side repair group, in which the distal stump of the peroneal nerve trunk was anastomosed to the lateral side of the tibial nerve. The third was the side-to-side repair group. In this technique, 1-mm diameter epineural windows, both from peroneal and tibial nerve trunks facing each other, were removed and side-to-side neurorrhaphy was performed. After 3 weeks, as the second step, the peroneal nerve was sectioned proximally. At 2, 4, 8, 12, 20, and 28 weeks, functional assessment of nerve regeneration was performed by using walking track analysis. The number of myelinated fibers and fiber diameters were measured and an electron microscopic evaluation was carried out. Statistically, both in morphometric and gait analysis, the differences in values between the groups were significant in favor of the control group, followed by the side-to-side group. The study showed that axonal passage was possible with side-to-side technique and the functional results were satisfactory and superior to the end-to-side technique. Continuous supply of neurotrophic factors from their target cells was the probable cause of superior functional return in side-to-side repair, because both joining nerves were intact and healthy during the anastomosis procedure and after 3 weeks. It was concluded that this technique could be indicated in salvage of nerves in cases for which any intermediate segments would be removed, as in tumor ablation surgery, harvesting of nerve grafts, or both.

Chemical delay: an alternative to surgical delay experimental study.

The delay phenomenon has long been recognized as a powerful adjunct to flap surgery. Currently, delay procedures remain a reliable method of maximizing flap survival. Although delay yields successful results, the necessity of an additional surgical procedure is a persistent disadvantage from both clinical and economic perspectives. The authors’ purpose is to demonstrate the usefulness of a novel chemical delay technique that obviates the need for a surgical delay procedure. This technique contains an epinephrine-loaded microsphere delivery system. In this study, 30 rats were subdivided into three groups of 10 animals. In group I, transverse rectus abdominis musculocutaneous (TRAM) flaps were delayed surgically 1 week before formal elevation. Group II (sham chemical delay) animals were injected with saline-loaded microspheres into the entire undersurface of the proposed TRAM flaps, which were elevated 1 week later. In group III rats, epinephrine-loaded microspheres were injected into the undersurface of the TRAM flaps to initiate a chemical delay 1 week before surgical elevation. Groups were compared via TRAM flaps 1 week after elevation. There was a significant difference between groups I and III in favor of surface area viability and angiographic assessment (p < 0.05). Surgical delay has traditionally been accepted to be the most reliable method of enhancing flap viability. Statistically similar results were obtained by chemical delay initiated by epinephrine-loaded microspheres. Chemical delay is less invasive, less time-consuming, and far more cost-effective compared with its surgical alternative. The chemical delay model lends further support to the role of relative hypoxia as the primary promoter of the delay phenomenon.

Single stage augmentation mastopexy: a novel technique using autologous dermal graft.

Mastopexy with augmentation is not an uncommon procedure in breast surgery. This combined procedure has been reported to result high rate of recurrent ptosis by several recent studies. The goal of this study is to introduce a novel technique that addresses the importance of 2 variables—breast position and inframammary fold location via autologous dermal graft, for an improved end results in augmentation mastopexy.Twenty-one patients operated over a period of 2 years from August 2005 through August 2007 were included in the study. The augmentation was performed first followed by adjusting the skin envelope and breast parenchyma to contour around the new breast volume. Augmentation/mastopexy with autologous dermal graft interpositioning, presented in this article, is a novel technique and the technique is described in detail.There were no major vital complications like death, major flap, or nipple necrosis. The most common complications seen were: inadequate circumvertical skin incision, inadequate transposition of nipple-areolar complex, overprojection of areola, and minor complications such as suture abscess. All complications were revised under local anesthesia. No recurrent ptosis was seen in any of the patients. Mean follow-up was 20.6 months (range, 14–36 months).Simultaneous augmentation mastopexy with autologous dermal graft interpositioning is a safe procedure. The dermal graft is easy to harvest. It is cost-effective. This technique ensures an improved breast appearance via securing the breast position and delineating the inframammary location. The very early results are promising but long-term results needed to be evaluated.

Does sustained epinephrine release trigger a hypoxia-neovascularization cascade?

Background: Recent data regarding the long-term local administration of epinephrine to soft tissues for the purpose of inducing prolonged vasoconstriction have yielded promising results. These studies postulated that long-term release of epinephrine by a microsphere/drug delivery system caused continuous vasoconstriction and subsequent vascular augmentation. The goal of this study was to test the hypothesis that epinephrine induces a hypoxia-neovascularization cascade and plays a primary role in vascular proliferation within soft tissues. Methods: Thirty male New Zealand White rabbits were randomly grouped as follows: group I, control (n = 10); group II, saline-loaded microsphere/drug delivery system injection (n = 10); and group III, epinephrine-loaded microsphere/drug delivery system injection (n = 10). A 2 × 1-cm rectangle was marked on the dorsal surface of the left ear of each rabbit. No solutions were injected in the control group, whereas 1 ml of saline-loaded and epinephrine-loaded microspheres was injected into groups II and III, respectively. A laser Doppler device was used to measure tissue blood volume and tissue blood flow. Results: Laser Doppler monitoring in tissue blood flow yielded a distinct difference between the epinephrine-loaded microsphere–injected group and the other two groups (p < 0.05). Conclusions: The ability of epinephrine-loaded microspheres to augment the vascular network in vivo is the result of sustained vasoconstriction with consequent tissue hypoxia and subsequent neovascularization. Data extracted from the present study, first, might be applied to improve hemostasis for operations typically plagued by serious intraoperative blood loss. Second, the ability to intentionally augment the vascularity of certain flaps before elevation should result in their increased survival. Radiation-injured tissues may also derive great benefit from this treatment.

Augmentation mammaplasty by reverse abdominoplasty (AMBRA).

Background: The purpose of this article is to describe a novel technique of providing autologous tissues for breast augmentation and simultaneously rejuvenating the abdomen. Methods: Thirty-seven patients underwent augmentation mammaplasty by reverse abdominoplasty (AMBRA) between 1997 and 2006. The upper abdominal pannus present in women whose lower abdomen was typically less aesthetically compromised was harvested as deepithelialized adipofascial flaps, maintaining their connection to and thus blood supply from the attached breast parenchyma. These flaps are transposed subglandularly, creating autologous tissue breast implants, and reverse abdominoplasty accomplishes donor-site closure and aesthetic improvement. If previous surgery or inadequate inframammary fold tissue thickness renders the superior circulation unfavorable, the upper abdominal tissues can be used as advancement flaps vascularly supplied by their attachment to the abdominal skin apron. Results: Twenty-three patients (62 percent) had simultaneous mastopexy and 16 (43 percent) had simultaneous panniculectomy. Complications in the superior pedicle group were minimal. In the inferior pedicle group, complications were more extensive because of the premorbidity of this group of patients and the limitations of this technique, where the resuspension of the abdominal wall apron is less facile and generally weaker than closure with superiorly based flaps. Conclusions: Augmentation mammaplasty by reverse abdominoplasty is a versatile procedure that in the carefully selected patient can successfully address two aesthetic concerns simultaneously, providing durable autologous tissue that can obviate or enhance the outcome provided by prosthetic implants and rejuvenating the abdomen. It also shows promise as a significant adjunct to the techniques available to the breast reconstructive surgeon.

Calf contouring with endoscopic fascial release, calf implant, and structural fat grafting.

Background: Curved lower legs cause psychological stress for women. In evaluating the shape, if thickness is the main contributing factor of leg aesthetic, then lipoplasty or calf reducing procedures will be the option. If the legs are slender and have no muscle hypertrophy but still have some indentation or bulges on both sides and lack an aesthetic shape what will be the options? The answer to the question is discussed in detail in this article. Methods: Twenty-two patients, operated over a period of 5 years from 2007 to 2012, were included in the study. A novel technique has been introduced. This method requires release of fascia covering muscles of the inner leg bulge via endoscopic approach and simultaneous calf augmentation with calf implant, liposuction, and structural fat grafting to optimize the results. Results: Patients were followed on a regular basis with a mean follow-up of 31 months. The procedure was well tolerated with minimal discomfort during the postoperative period. Increase in diameter of proximal and distal lower legs was measured at least 6 months after surgery. Mean diameter change of proximal lower legs was 2.16 cm and 1.77 cm in distal lower legs. Conclusions: A novel endoscopic approach for lower leg contouring is discussed. Endoscopic fasciotomy technique with calf implant and structural fat grafting for improved lower leg aesthetics is a simple, effective, reliable, and predictable technique for calf contouring.

Rotation ligamentoplasty for the correction of epicanthus inversus.

&NA; Epicanthus, with its various types, is characterized by an arching fold at the sides of the nose, with a concavity directed laterally. Epicanthus inversus, one of these types, which occurs with varying frequency in all races, is most common among Asians. In epicanthus inversus, the medial canthus is displaced laterally and the medial canthal depression is shallow or absent. The lower puncta is displaced laterally as well. Correction of epicanthus is easy with Z‐plasties or with the four‐flap technique of Mustardé. However, inverted epicanthus cannot be repaired using these techniques, as proved by others. The authors suggest rotating the medial canthal ligament during transnasal wiring to support the eversion of the laterally displaced medial lower lid, lower puncta, and surrounding skin. Eight patients with epicanthus inversus were operated and followed for at least 15 months. The results were satisfactory according to a graded scale. Karacaoğlu E, Tezel E, Güler MM. Rotation ligamentoplasty for the correction of epicanthus inversus. Ann Plast Surg 2000;45:140‐144

Bilateral macrostomia as an isolated deformity and its repair with a modified technique

A 3-year-old boy with bilateral congenital macrostomia as an isolated clinical entity is presented. Although this is a rare deformity, it causes functional and cosmetic problems which are difficult to correct. The skin, muscle, and mucosal components of the deformity were separately repaired using a modification of Kaplans technique.

Wiping Away Debris Between Passes During Laser Surgery: Is It Really Efficient or Causing Complications?

Abstract. Although carbon dioxide laser skin resurfacing offers a controlled and predictive tissue ablation, it is not completely without complications, such as cobblestone-like appearance or scar formation. It has been supposed that these were the results of thermal loading on overlapped areas. In order to obtain a smoother surface, an experimental study dealing with the effect of wiping procedure between the sessions was carried out. Laser beams were applied in two sessions to the backs of 20 rats. Between the sessions, the debris was wiped away in half and left unwiped in the others. Despite a statistically higher ablation rate in the wiped group, its surface irregularity was statistically significant when compared to unwiped group.It is supposed that the amount of debris left on the surface has the regulatory role in laser application. Because laser beams can be absorbed more by untreated skipped areas and less by overlapped sites, the second pass can ensure a smoother surface. Considering both benefits and disadvantages, it is concluded that wiping vaporized debris every two passes is the most reliable laser treatment modality.