Erhan Sönmez

Flow-through Free Latissimus Dorsi Flap for Reconstruction of Injured Limbs: Evaluation of Hemodynamic Effects on Extremity Circulation

Management of vascularized injured extremity requires careful reconstruction for continuity of leg circulation. Protection of the remaining intact vessels during free flap transfer provides condition for blood flow maintenance in the distal extremity. Latissimus dorsi muscle has the correct vessel anatomy for applying flow-through flap because it protects recipient vessel integrity during soft tissue reconstruction. Flow-through flap circulation may cause decreasing blood flow in the recipient artery and steal phenomenon in distal circulation although the main vessel remains intact. The purpose of this study was to describe blood flow changes in the recipient artery, flap pedicle, and distal leg circulation at early and long-term follow-up periods. For this purpose, evaluations of blood flows by using Doppler ultrasonography were performed in 2 vascularized injured extremities which were reconstructed with flow-through free latissimus dorsi musculocutaneous flaps. The results demonstrate that flow-through flaps in our vascularized injured extremity did not disturb distal leg circulation in spite of increased blood flow in the recipient and pedicle arteries.

Free flap transfer to the dorsum of the rat: a new technique to avoid autocannibalization in free flap studies.

In this report the authors describe a new method that avoids autocannibalization by free transfer of a flap to the dorsum of the rat by means of a simple exposure technique. A total of 22 Wistar rats of both sexes (weight, 200–290 g) were used in this experiment. An anatomic study performed in 12 rats revealed that a wide exposure could be created in the axillary fossa by retracting the inferior tip of the scapular bone superiorly (after severing its attachments with the deep extrinsic back muscles), the latissimus dorsi muscle laterally, and the serratus anterior muscle medially. Furthermore, after obtaining vessel diameter measurements, it was ascertained that the subscapular and the lateral thoracic vessels could serve as the recipient vessels. Based on the anatomic study, a total of 10 conventional groin cutaneous flaps, measuring 2 × 3 cm in size, were harvested based on the femoral vessels and transferred to the dorsum of the same animal by the exposure method as just described, with microvascular anastomoses performed between the femoral vessels of the flap and either the subscapular artery and the lateral thoracic vein (N = 5) or the lateral thoracic artery and vein (N = 5). Results showed that 9 of the 10 transplanted flaps were totally viable on postoperative day 7, giving a success rate of 90%, with one failing flap belonging to the latter group. The authors conclude that by this simple method of recipient vessel exposure in the axillary fossa, free flap transfer to the dorsum of the rat is a simple and reproducible technique by microvascular anastomoses performed between the pedicle vessels of a flap and the subscapular artery and the lateral thoracic vein. This model offers the unique advantage of a dorsally located flap that is protected by autocannibalization. Moreover, daily observation and monitoring of the flap are easy and practical without the need to have the animal wear protective material such as vest.

Iliac crest flap for mandibular reconstruction after advanced stage mandibular ameloblastoma resection.

Abstract Ablative surgeries for neoplastic processes of the oral cavity, traumas, infections/inflammations, osteoradionecrosis, and congenital deformities are the most common causes of large mandibular defects. Ameloblastoma is a locally aggressive tumor that, if not treated, can gain an enormous size and cause severe facial disfigurement and functional impairment. Although the smaller lesions of ameloblastoma in the mandible are treated by conservative approaches such as marsupialization, enucleation, and curettage combined with liquid nitrogen spray cryosurgery, larger lesions require radical surgical ablation procedures resulting in large tissue defects. A large mandibular defect has deleterious effects on a person’s life, with a significant loss in the quality of life unless it is reconstructed successfully. The aim of present case series report is to show the results of the multidisciplinary treatment of patients with advanced stage ameloblastoma, including tumor resection, simultaneous reconstruction with iliac crest flap, followed by placement of endosseous dental implants, and finally the prosthodontic rehabilitation.

Soft-tissue management with immediate free flap transfer in segmental prosthetic replacement of proximal tibia sarcomas

Knee reconstruction with endoprosthesis after tumor resection is accepted as superior when compared with the other methods. But sometimes soft tissue reconstruction would be a challenging problem in this way of treatment. Five patients who were operated for tumor resection in this location, followed by reconstruction were presented with their one‐year post operative results. Four latissimus dorsi and one rectus abdominis myocutaneous free flaps were used in these patients in order to manage soft tissue problems. All patients underwent chemotherapy in postoperative period. All flaps were successful in one year post operative examination. In this report we would like to stress the importance of surgical planning and soft tissue reconstruction of a specific patient population. We think that large musculocutaneous flaps such as latissimus dorsi and rectus abdominis musculocutaneous flaps should be preferred in soft tissue reconstruction of knee region after tumor resection followed by prosthetic replacement. Additionally, this way of treatment is superior when compared to the other methods in order to prevent complications such as prosthesis exposure or infection.

Easy method of capturing microscopical images by using a consumer-type digital camera.

Taking pictures of microstructures is difficult, requiring sophisticated cameras coupled by the microscopes. Furthermore, it may not be feasible to find an operating microscope paired with a camera, especially in laboratory conditions. Considering the difficulty of obtaining microscopic photographs in clinical and laboratory settings, this report describes a practical method of digital photography of microstructures using a consumer-type digital camera. The technique can be summarized simply as placing the lens of a consumer-type digital camera over the eyepieces of a surgical microscope, whereby the anatomic structure of interest is focused. The image thus obtained is transferred to the computer, using easily available software programs. The authors conclude that this method is an inexpensive and practical way of capturing photographs of microstructures, obviating the need for using microscopes coupled by the cameras.

Giant nodular cystic fat necrosis: a report of a rare case

rationality and adopt Noordhoff’s lateral vermillion flap technique into their own procedures for cleft lip repair. 6 In fact, these vermilion flap techniques are believed to be useful in that they enlarge the height of the vermilion; however, we consider that there are certain patients whose labial tubercles are severely hypoplastic, and the vermilion flap alone cannot be used for complete reconstruction. As Kun et al. pointed out using adult cadavers, the thickness of the pars marginalis varied widely between cases. Moreover, as Stephen et al. reported, the muscle fibres near the cleft show varying degrees of atrophy (though they obtained specimens from para-alar lesions), we believe that certain cases may exhibit latent and critical deficiency of the labial tubercle because of the existence of latent bilateral deformities in unilateral clefts. Because we do not have sufficient experience in vermilion flap techniques, we cannot comment on his technique in great detail; however, we believe that the cases reported in the literature are equally effective, but some of their labial tubercles remain deficient. Our surgical technique reported in this article aims to correct this type of deformity and reconstruct the labial tubercle more aggressively. In practice, while operating, we use the V-Y advancement technique first, and additionally perform the Z-plasty red line reconstruction technique, if required. In such cases that it is very difficult to adapt each end of the red line using simple suturing, the vermillion height on the affected side usually appears to be excessive. Therefore, we believe that Z-plasty red line reconstruction is a reasonable procedure in that it enlarges the vermillion height of the unaffected side and simultaneously reduces that of the affected side. Of course, we do not believe that the V-Y advancement technique alone is effective in all cases, but our technique introduced here is one useful technique which can correct a wide variety of cleft lip deformities. In conclusion, during primary cleft lip repair, in cases in which the usual vermillion plasty does not achieve a satisfactory volume of the labial tubercle, our V-Y advancement vermillion plasty can be a useful supplementary technique.

The cranially based contralateral nasolabial flap for reconstruction of paranasal and periorbital surgical defects

The importance of the paranasal and periorbital regions on the aesthetics of the face presents a variety of reconstructive challenges for surgical and traumatic defects of those regions. We used the cranially based nasolabial flap in patients with full-thickness soft-tissue defects of the paranasal and periorbital regions harvested from the contralateral side of the present defect. We present our experience in 25 patients of geriatric population (13 females and 12 males with a mean age of 76) with complex soft-tissue defects in the paranasal and periorbital regions whose defects were reconstructed with contralateral nasolabial skin flaps. Sizes of the defects changed between 2 × 3 cm and 6 × 7 cm. The flap sizes varied from a width of 2 to 5 cm (average 3 cm) and a length of 7 to 11 cm (average 8 cm). Primary closure of the donor sites of the flaps was possible in 24 of the patients in this series. Twenty-one flaps of this series (84%) healed without any necrosis and completely survived. The contralateral nasolabial flap is a very convenient, safe and reliable flap that can be used in medium to large paranasal and periorbital defects. Optimal aesthetic results for a variety of central facial defects could be obtained with this flap, especially when the ipsilateral nasolabial flap cannot be used due to various reasons.

Free groin flap applications in the pediatric population.

The popularity of the groin flap has gradually decreased because of the disadvantages related to its short pedicle and technically demanding harvesting. We have summarized our experience with free groin flap applications in the pediatric population, which were performed by the same surgeon between 2004 and 2007. A total of 10 free groin flap transfers were performed in patients aged 3 to 13 years. Nine of the patients were operated on because of contractures of the extremities (six lower, three upper), and one patient was operated on for facial contour augmentation. The total duration of the operation was estimated to be between 2.6 and 6.1 hours (mean: 4.1 hours). A revision of the anastomosis was performed in two patients (20%), and in one of these patients (50%) partial flap failure was seen. Flap defatting via liposuction was performed in four patients (40%) in the late postoperative period. In our opinion, donor site morbidity comes into prominence particularly in the pediatric population, and we think that free groin flap should be the first choice of free flap for suitable cases in this group of patients.

Interpositional vein graft suturing over temporary silastic tube.

Interpositional vein grafting is the gold standard for the replacement of vascular defects. Although many microsurgeons have used classical suture anastomosis successfully, it is still technically challenging, especially for the inexperienced surgeon. We present a new technique that facilitates autogenous vein grafting by using a commercially available silastic tube employed temporarily during the suture anastomosis and removed at the end of the procedure. Effects of this technique on operative time and patency were tested by an experienced and an inexperienced microsurgeon. Each surgeon operated on a total of 20 rats divided in experimental and control groups of 10 animals each. The experimental group was operated on with silastic-tube-assisted suture anastomosis, and the control group was operated on using the classical suture anastomosis without using the device. For the experienced microsurgeon, proposed modification resulted in a statistically significant reduction in operative time without an effect on patency. For the inexperienced microsurgeon, the proposed modification resulted in a statistically significant reduction in operative time and also enhanced patency rates significantly. Interpositional vein grafting over a temporary silastic tube is a practical modification of the classical microvascular anastomosis that adds speed and ease to the microvascular vein grafting procedure and prevents back-wall biting, particularly for inexperienced microsurgeons.

Simultaneous forequarter amputation and radical mastectomy for metastatic breast carcinoma in a male patient: a case report

Although the majority of forequarter amputations are performed for high-grade bone and soft tissue sarcomas or extensive osteomyelitis of the upper extremity, this radical operation may also be indicated for the curative treatment of recurrent breast cancer and for the palliation of locally advanced breast cancer. We report a male patient with metastatic breast adenocarcinoma who underwent simultaneous mastectomy and forequarter amputation for the management of both his primary and metastatic disease.