Erdem Güven

Hemifacial resurfacing with prefabricated induced expanded supraclavicular skin flap.

BACKGROUND Severe facial burn sequelae present a great challenge and maximally test the principles of reconstructive surgery. Three of these basic principles--free tissue transfer, flap prefabrication, and tissue expansion--are combined to achieve superior reconstructive outcomes. This approach evolved into the prefabricated induced expanded flap, which refers to the staged transfer of expanded supraclavicular skin with an antebrachial fascial free flap used as the carrier. METHODS In the first surgical stage, the radial artery and corresponding vein in antebrachial fascia were transferred to a subcutaneous pocket in the supraclavicular fossa over a large skin expander, with anastomoses to the neck vessels. During the second stage, after adequate expansion lasting 2 to 3 months, the total scarred hemiface was excised, and the prefabricated induced expanded flap was dissected and then transferred as an island to cover the skin defect. RESULTS Twenty-six patients with severe hemifacial burn sequelae and three more with other large hemifacial lesions underwent successful facial resurfacing with the described technique in the last 7 years. Twenty patients were male and nine were female, with a mean age of 23. Mean follow-up was 3.4 years. All of the flaps survived after transfer, and no major complication was observed. CONCLUSIONS The supraclavicular prefabricated induced expanded flap can provide ample amounts of vascularized, thin, and desirable skin with perfect color match for resurfacing major facial defects. The aesthetic and functional results were encouraging and progressively improved during follow-up.

Ultrasonographically determined pedicled breast reduction in severe gigantomastia.

Background: The free nipple breast reduction method has certain disadvantages, such as nipple hyposensitivity, loss of lactation, and loss of projection. To eliminate these risks, the authors describe a patient-based breast reduction technique in which the major supplier vessels of the nipple-areola complex were determined by color Doppler ultrasonography. Pedicles containing these vessels were designed for reductions. Methods: Sixteen severe gigantomastia patients with a mean age of 41 years (range, 23 to 60 years) were included in the study. Major nipple-areola complex perforators were determined with 13- to 5-MHz linear probe Doppler ultrasonography before surgery. Pedicles were designed according to the vessel locations, and reductions were performed with superomedial-, superolateral-, or mediolateral-based designs. Results: Different combinations of internal mammary and lateral thoracic artery perforator–based reductions were achieved. None of the patients had areola necrosis. Mean reduction weight was 1795 g (range, 1320 to 2280) per breast. Conclusions: Instead of using standard markings for severe gigantomastia patients, custom-made and sonographically determined pedicles were used. This technique can be considered as a “guide” for the surgeon during very large breast reductions.

Sensory recovery of the reverse homodigital island flap in fingertip reconstruction: a review of 66 cases

OBJECTIVES The location of the fingertip entitles it to have significant cosmetic and functional values, but also places it at high risk for injury. During repair, finger length and function should be maintained, and stiffness and neuroma should be avoided. Various flaps have been described for reconstruction of distal finger defects with bone, tendon, or joint exposures, including reverse flow homodigital island flap. In this study, we present our experience of reverse flow homodigital island flap in terms of sensory recovery. METHODS Sixty-six patients (70 fingers) with fingertip amputations were included in the study. Patients were treated with homodigital island flaps. All patients underwent sensitivity assessment by 2-point discrimination and Semmes-Weinstein monofilament tests at 6, 12, and 18 months during follow-up, and complications were recorded. RESULTS Monofilament testing results were normal in 64 fingers (91.4%), and diminished light touch was found in six fingers. Two-point discrimination results were normal (<6 mm) in 40 fingers and fair (6-10 mm) in 30 fingers (mean 5.7 mm, range 4-9 mm). Complications included one partial flap necrosis, three flexion contractures, and two neuromas. CONCLUSION In repair of injuries to areas in which sensory feedback is critical, such as the index finger, the homodigital flap may be the treatment of choice.

Does partial expander deflation exacerbate the adverse effects of radiotherapy in two-stage breast reconstruction?

BackgroundThe optimum protocol for expander volume adjustment with respect to the timing and application of radiotherapy remains controversial.MethodsEighteen New Zealand rabbits were divided into three groups. Metallic port integrated anatomic breast expanders of 250 cc were implanted on the back of each animal and controlled expansion was performed. Group I underwent radiotherapy with full expanders while in Group II, expanders were partially deflated immediately prior to radiotherapy. Control group did not receive radiotherapy.The changes in blood flow at different volume adjustments were investigated in Group II by laser Doppler flowmetry. Variations in the histopathologic properties of the irradiated tissues including the skin, capsule and the pocket floor, were compared in the biopsy specimens taken from different locations in each group.ResultsA significant increase in skin blood flow was detected in Group II with partial expander deflation. Overall, histopathologic exam revealed aggravated findings of chronic radiodermatitis (epidermal atrophy, dermal inflammation and fibrosis, neovascularisation and vascular changes as well as increased capsule thickness) especially around the lower expander pole, in Group II.ConclusionsExpander deflation immediately prior to radiotherapy, may augment the adverse effects, especially in the lower expander pole, possibly via enhanced radiosensitization due to a relative increase in the blood flow and tissue oxygenation.

Electrothermal Bipolar Vessel Sealer in Endoscope-Assisted Latissumus Dorsi Flap Harvesting

LigaSure™ is a new bipolar vascular sealing system commonly used in various fields of surgery. However, no reports have been published about its use in plastic surgery, particularly for endoscopic flap harvesting. In this study, we present the use of LigaSure in endoscope-assisted latissimus dorsi (LD) flap harvesting for breast reconstruction. Between 2006 and 2008, 11 female patients with the mean age of 33.4 (range, 20-49 years) who had previously undergone mastectomy operations were included in the study. First stage of reconstruction was performed with the ipsilateral LD harvested by the help of LigaSure and a tissue expander placed beneath the LD and pectoralis major muscles. Secondary reconstruction was done by a definitive silicon gel-filled implant placed after an average of 6.6 months of expansion (range, 6-9 months). Data concerning the hospitalization and operation times, drainage amounts, complications, etc., were recorded. Mean follow-up was 13 months (range, 8-18 months). Mean flap harvesting time was recorded as 74.2 minutes (range, 50-125 minutes), which shortened as the surgeon got used to the procedure. Patients were hospitalized for 3-7 days, with a mean hospitalization period of 5.5 days. The total mean drainage amount postoperatively was found to be 950 mL (range, 725-975 mL), which is relatively lower than the previously reported values. LigaSure use in endoscope-assisted LD harvesting is easy, safe, and time sparing with almost no complications observed in this small initial series. Although more controlled studies with larger number of patients need to be done to verify its effectiveness in terms of hospitalization, drainage amounts, etc., it holds promise for a wide spectrum of operations in the field of plastic surgery.

A custom-made silicon mold for pressure therapy to ear keloids.

Keloids are raised reddish nodules that develop at the site of an injury. They are characterized histologically by an abundance of fibroblasts, thick collagen bundles, and ground substance. Auricular keloid formation is a known complication of ear piercing. Many types of treatments have been described for auricular keloids. Pressure therapy in combination with surgery, corticosteroid injection, or both is widely used to manage and prevent hypertrophic scarring. Many pressure devices and procedures have been developed. However, all of them are designed for the earlobe region. If a keloid grows in the posterior auricular region, none of the devices described in the literature will be effective. The authors developed a custom-made silicon ear mold that covers whole ear. With this mold, pressure can be applied homogeneously to the lobule and cartilaginous region, which the other devices described in the literature cannot affect. The preparation technique includes making the negative cast mold of the patient’s ear, creating the positive cast mold from the negative cast mold, and forming the negative silicon mold from the positive cast. After all the processes, a silicon sheet has been designed according to the region needing to be pressurized. The designed silicon sheet is applied to the region, followed by placement of the silicon mold. A simple tennis headband can be used to stabilize the silicon cast. If the keloid extends to the posterior auricular region, pressurizing with clips or other devices described previously will be difficult. Application of pressure to the cartilaginous auricle needs custom-made devices. At this point, a pressure sore caused by a device applied to the ear is the most important problem. To prevent the ear from developing a pressure sore, the device should press to whole area homogeneously. For this reason, the device applied for pressure therapy to the ear must be custom made.

Facial contour reconstruction with temporoparietal prelaminated dermal–adipose flaps

AIM Compared with those for free-fat grafts, resorption rates for vascularized adipose tissue transfers are very low. We analysed benefits of transfer of dermal-adipose grafts after prelamination upon the temporal fascia in reconstruction of facial contour defects. PATIENTS AND METHODS Among 8 patients operated on between 2005 and 2008, facial contour anomalies had resulted from trauma in 5, while the remaining 3 had abnormalities with a congenital, postinfectious, or iatrogenic aetiology. In the first-stage operation, a dermal-adipose graft was taken from the inguinal region and prelamination upon the superior surface of the temporal fascia. After 5.5 months, the prelaminated dermal-adipose-fascial flap was raised as an island flap, passed through a subcutaneous tunnel in the temporal region, and set into the defect site. RESULTS Satisfactory cosmetic results were achieved in all patients. Except for a temporary frontal nerve palsy in 1 patient, no early or late complications resulted from this procedure. CONCLUSION Prelamination of dermal-adipose grafts upon the temporoparietal fascia is useful in reconstruction of soft tissue defects requiring volume augmentation.

Our treatment approaches in head-neck injuries caused by animal bites

Several approaches exist for the treatment of animal attacks targeting the head and neck region. The treatment options and timing vary depending on the animal species, the nature of the defect, and the experience of the surgeon. In this study, early surgical treatment options used in head-neck injuries caused by domesticated or wild animal attacks are presented.We consider 12 patients who were admitted to our clinic between June 2006 and May 2010 with head-neck injuries caused by animal attacks. Tissue defect had developed in 10 patients due to half-wild dog bite and in 2 patients due to wolf bite. The ages of the patients ranged from 3 to 45 years (mean, 21.3 years). Among the patients included in the study, 4 had facial injury, 3 had ear, 3 had scalp, 1 had eye, and 2 had nose injuries. In all patients, early surgical reconstruction was performed after irrigation, antisepsis, and debridement. Concurrent rabies and tetanus prophylactic antibiotherapy program was started.Infection or surgical complications were not observed in any of the patients. Rabies symptoms were determined in one of the quarantined dogs under surveillance. There were no positive findings in the patient bitten by the dog. The surgical treatment results from all patients were at satisfactory levels.As a result, it is observed that, in the treatment of head and neck injuries resulting from animal bites, early acute approach has replaced the traditional long-term treatment. We believe that debridement and early surgical reconstruction used in combination with medical support and prophylactic treatment are the best treatment method.

Body fat composition and weight changes after double-jaw osteotomy.

Nutritional problems might be observed after surgical procedures. In this study, body weight and fat composition changes have been investigated in dentofacial deformity patients after the double-jaw osteotomy procedure.Thirty Angle class 3 patients operated on with double-jaw osteotomies during the period of March 2006 to July 2008 were included in the study. Interocclusal splints were applied continuously in the first 2 weeks after surgery, whereas intermittent splint was used for the next 2 weeks. Patients were analyzed before surgery and on the first month after surgery with the help of Tanita Composition Analyzer 310 bioimpedance method for weight, fat mass, and fat-free mass values. Results were evaluated statistically with the paired-sample test using SPSS version 13.0.Although significant results were obtained in female patients before surgery (weight [P = 0.011], body mass index [BMI; P = 0.012], fat mass [P = 0.010], and fat-free mass [P = 0.051, not significant]), none of the values were significant for male patients (P = 0.747, P = 0.747, P = 0.645, and P = 0.803, respectively). Weight gain was observed in 9 patients (30%). In contrast, weight gain was not seen in underweight patients. No sex differences in terms of weight gain/loss and fat composition have been observed.Interocclusal splint in female patients operated on with double-jaw osteotomies might cause nutritional deficiency in the first month after surgery. This eventually causes fat and weight loss, which may lead to poor wound healing and recovery later.

Prosthetic rehabilitation of a patient after surgical reconstruction of the maxilla: a clinical report.

Prosthetic management of maxillectomy cases is challenging, and a multidisciplinary approach is usually needed. This clinical report describes the treatment provided to a patient who presented with a moderately differentiated squamous cell carcinoma. A two-stage surgical protocol was followed for this purpose. At the first surgery, the anterior maxilla was resected, and the oral and nasal mucosal and osseous defect was reconstructed with an osteocutaneous flap from the radial forearm. At the second surgery, all fascias and the connective tissue between the skin and the bone were resected to provide an optimal thickness for denture stability. Two months after the second surgery, prosthetic rehabilitation was completed with a maxillary telescopic overdenture. During the 15-month follow-up period, the patients oral condition and physical appearance improved, and no complications occurred.