Erkan Orhan

Trauma: a new pseudogynecomastia cause.

Male breast enlargement is a frequently seen condition. There are two causes for male breast enlargement: glandular proliferation and increased fat deposition. If it is caused by glandular proliferation, it is defined as gynecomastia. If it is caused by increased fat deposition, it is defined as pseudogynecomastia. Hormonal aberrations, carcinoma, endocrine disease, systemic disorders, and drugs can cause pathologic breast enlargement [1, 2]. We report a case of unilateral pseudogynecomastia and suggest a new cause of pseudogynecomastia: trauma. A 49-year-old male patient came to our clinic because of enlargement of the right breast. He had worked in a manual metal-pressing factory for 25 years. Physical examination revealed a body mass index (BMI) of 30 but no other pathologic findings, except his breast enlargement and asymmetry. A grade III gynecomastia of the right breast and a grade I gynecomastia of the left breast were noted (Fig. 1). Pectoralis muscle examination revealed no signs of hypertrophy or asymmetry. Endocrine status tests showed normal hormonal values. Ultrasound and mammography of the enlarged right breast demonstrated homogeneous fibrofatty tissue, with no mass or calcifications. The patient underwent skin and fat tissue excision with free-nipple grafting in one session. Histologic examination of the breast reduction tissues showed a pseudogynecomastia pattern, with no evidence of lymphatic abnormality, ductal tissue proliferation, or carcinoma. Our patient and coworkers hold and immobilize a firm rod under their right armpit during the shaping of a metal plate (Fig. 2) and thereby sustained chronic vibration, pressure, and irritation to their pectoral region over the years. The pathophysiology of this pseudogynecomastia formation could be similar to the theories of post-traumatic lipoma formation. Most of these theories suggested that post-traumatic lipoma was caused by shifting of the fat tissue between different anatomical levels as prolapses of normal adipose tissue, although a deficiency in the overlying Scarpa’s fascia [3], the rupture of the septa in which the fat is normally contained under pressure, and its herniation [4]. In our case, there was only one fat tissue level, S. Erol E. Orhan (&) A. Sevin B. Erdoğan Department of Plastic and Reconstructive Surgery, Ankara Numune Training and Research Hospital, 60. SK. 132/11, Emek, Ankara 06510, Turkey e-mail: eorhan@yahoo.com Fig. 1 Preoperative view of the patient

A New Oval Advancement Flap Design for Reconstruction of Pilonidal Sinus Defect

BackgroundsPilonidal sinus is a common chronic disease of the sacrococcygeal region. Although many surgical methods have been described for treating pilonidal sinus disease, controversy still exists as to the best surgical technique. The aim of this study is to present a new modified advancement flap technique named “omega flap” for the treatment of pilonidal sinus disease.Materials and methodsThis study included 18 patients with pilonidal sinus who were treated between March 2012 and August 2014. All cases underwent oval excision and omega advancement flap reconstruction. Defect size, postoperative complications, postoperative pain, painless sitting time, patient satisfaction and recurrence were evaluated retrospectively.ResultsAll patients were discharged on the first postoperative day. There was no flap necrosis. No recurrence and no major complication were observed during follow-up period. The outcomes were also satisfactory regarding functionally and aesthetically, and the patients were satisfied with the results.ConclusionsPresented method has a different geometry than classical advancement flap methods. Our technique provides two-layered repair with minimal tension and off-midline closure for the reconstruction of pilonidal sinus defect. It is easily performed, reliable, associated with no recurrens and good aesthetic results.

Collateral circulation between angiosomes in the feet of diabetic patients

Objectives The main factor in the healing of foot ulcers in diabetic patients is adequate perfusion. There is no consensus on whether direct or indirect revascularization is more effective in leg revascularization. At the centre of that debate, there is a disagreement about whether collateral circulation is sufficient or not. Our aim is to evaluate collateral circulation activity between angiosomes in the feet of diabetic patients by evaluating the level of occlusion in leg arteries and comparing the angiosome regions that have necrosis. Methods The study included 61 patients. All had undergone CT angiography to the lower extremity prior to any revascularization of the leg arteries between September 2014 and September 2016. Stenosis was evaluated on the anterior tibial artery, the posterior tibial artery and the peroneal artery up to the level of the ankle. The opening of the vessel wall at the narrowest part of the vessel was determined as a percentage. The areas with necrosis were determined according to the angiosomes of the posterior tibial artery, anterior tibial artery and peroneal artery vessels. Results Necrosis of the foot was most common in the posterior tibial artery angiosome. Necrosis in the posterior tibial artery angiosome was independent of the level of posterior tibial artery occlusion; however, it was associated with the occlusion of the anterior tibial artery (p < 0.05). It was found that anterior tibial artery occlusion over 15% resulted in necrosis in the posterior tibial artery angiosome. Conclusions Collateral circulation between the anterior tibial artery and posterior tibial artery is active and there is almost always occlusion in the posterior tibial artery branches. The posterior tibial artery angiosome is fed by the collateral arteries of the anterior tibial artery even if there is no occlusion of posterior tibial artery at the level of the leg, so indirect revascularization on the anterior tibial artery is sufficient to provide foot circulation.

An unusual transoral penetrating injury by scissors in a child and principles of management

DOI: 10.4328/JCAM.5437 Received: 14.10.2017 Accepted: 13.11.2017 Publihed Online: 13.11.2017 Printed: 01.03.2018 J Clin Anal Med 2018;9(2): 155-7 Corresponding Author: Erkan Orhan, Reşat Nuri Sok. 71/31 Y.Ayrancı, Çankaya, Ankara, 06510, Turkey. GSM: +905325004192 F.: +9

Topukta Minimal Deviasyon Melanomu

Minimal deviation melanomas (MDM) are melanocytic tumours that were more atypical than ordinary nevi but less atypical than conventional melanomas. Histologically they are expansive growth of atypical melanocytes with expansion into the reticular layer of the dermis (Clark level IV). Seventy years old man, applied our clinic for a mass on his left heel. On examination, a 2x2 cm size, brown solid mass that has ulceration on surface was visible on inferior of left medial malleol. The mass was excised with a 1 cm margin and defect was reconstructed by skin grafts. After pathological examination that mass was explained as MDM. MDM’s hold on a point between benign nevus and the typical, biologically aggressive malignant melanoma. The metastatic potential of MDM is lower than malign melanoma. Most of the initial reports recommended a “less aggressive” form of therapy for MDM because of their more favourable outcome.

Using negative pressure therapy for improving skin graft taking on genital area defects following Fournier gangrene

OBJECTIVE Fourniers gangrene is an infective necrotizing fasciitis of the perineal, genital and perianal regions. Treatment includes aggressive surgical debridement that often results in extensive loss of genital skin. Skin grafts may be used for reconstruction but skin grafting of the male genitalia is diffucult because the penis and scrotum are mobile and deformable. A variety of methods are used to secure skin graft to recipient beds. We used negative pressure therapy (NPT) to secure skin grafts and improve skin graft taking. MATERIAL AND METHODS We used negative pressure therapy for graft fixation in 13 male patients who underwent debridements with the indication of Fournier gangrene, and whose defects formed were reconstructed with grafts between January 2009, and January 2014. Information about age of the patients, sessions of negative pressure therapy applied before, and after reconstruction, duration of hospital stay, and graft losses during postoperative period were recorded. RESULTS Median age of the patients was 56.15 (46-72) years. NPT was applied to patients for an average of 6.64 sessions (4-12) before and 1 sessions after graft reconstruction. Patients were hospitalized for an average of 26.7 (20-39) days. Any graft loss was not seen after NPT. CONCLUSION Because of the peculiar anatomy of the genital region, anchoring of grafts is difficult so graft losses are often encountered. Use of NPT for ensuring graft fixation on the genital region prevents skin graft shearing.

The protective effect of cilostazol on transverse rectus abdominis myocutaneous flap in rats

Abstract Objective: Transverse Rectus Abdominis Myocutaneous (TRAM) flap is commonly used in breast reconstruction. The aim of this study is to demonstrate the effects of cilostazol on TRAM flap viability in a rat TRAM model. Methods: Twenty-four Wistar rats were used. They were divided into four groups. Rats in Group 1 were applied TRAM flap. In Group 2, cilostazol 30 mg/kg was administered to rats via oral gavage 3 hours before the flap surgery. After the flap surgery, cilostazol 30 mg/kg was administered via oral gavage twice a day for 7 days. In Group 3 before the flap surgery, cilostazol 30 mg/kg was administered via oral gavage twice a day for 7 days, and treatment continued for 7 more days after the flap surgery. In Group 4 before the flap surgery, cilostazol 30 mg/kg was administered via oral gavage twice a day for 7 days and treatment was discontinued after the flap surgery. Result: The mean necrosis rate in Group 1 was 41.69%, in Group 2 it was 27.0%, in Group 3 it was 6.66%, and in Group 4 it was 11.2%. The necrosis rate in Group 1 was found to be statistically significantly higher than other groups (p < .01), the necrosis rate in Group 2 was found to be statistically significant higher than Groups 3 and 4 (p < .01), and the necrosis rate in Group 4 was found to be statistically significant higher than Group 3 (p < .01). Conclusion: Cilostazol treatment seemed to increase the viability of TRAM flap, especially when administered as adjuvant therapy.

Effects of Remote Ischemic Conditioning Methods on Ischemia-Reperfusion Injury in Muscle Flaps: An Experimental Study in Rats

Background The aim of this study was to investigate the effects of remote ischemic conditioning on ischemia-reperfusion injury in rat muscle flaps histopathologically and biochemically. Methods Thirty albino rats were divided into 5 groups. No procedure was performed in the rats in group 1, and only blood samples were taken. A gracilis muscle flap was elevated in all the other groups. Microclamps were applied to the vascular pedicle for 4 hours in order to achieve tissue ischemia. In group 2, no additional procedure was performed. In groups 3, 4, and 5, the right hind limb was used and 3 cycles of ischemia-reperfusion for 5 minutes each (total, 30 minutes) was applied with a latex tourniquet (remote ischemic conditioning). In group 3, this procedure was performed before flap elevation (remote ischemic preconditoning). In group 4, the procedure was performed 4 hours after flap ischemia (remote ischemic postconditioning). In group 5, the procedure was performed after the flap was elevated, during the muscle flap ischemia episode (remote ischemic perconditioning). Results The histopathological damage score in all remote conditioning ischemia groups was lower than in the ischemic-reperfusion group. The lowest histopathological damage score was observed in group 5 (remote ischemic perconditioning). Conclusions The nitric oxide levels were higher in the blood samples obtained from the remote ischemic perconditioning group. This study showed the effectiveness of remote ischemic conditioning procedures and compared their usefulness for preventing ischemia-reperfusion injury in muscle flaps.

The effect of intradermal administration of inactive platelet-rich plasma on flap viability in rats

Purpose: To evaluate the effect of inactive form of platelet rich plasma (PRP) on the flap viability. Methods: Thirty six rats were used. Rats were divided into six groups then 9x3 cm random pattern skin flaps were elevated from dorsum of all rats. For precluding vascularization from the base, a silicone layer was placed under the flap in groups 2(only flap+silicone), 4(saline+silicone) and 6(PRP+silicone). In groups 1(only flap), 2(only flap+silicone) nothing was done except flap surgery. In groups 3(saline) and 4(saline+silicone), saline was applied intradermally , in groups 5(PRP) and 6(PRP+silicone), inactive form of PRP which obtained from different 16 rats was applied intradermally, into certain points of flaps immediately after surgery. After 7 days flap necrosis ratio was measured in all groups. Results: Mean necrosis rate in group 5(PRP) (16.05%) was statistically significantly lower than group 1(only flap) (31,93%) and group 3(saline) (30,43%) (p<0.001). Mean necrosis rate in group 6(PRP+silicone) (36.37%) was statistically significantly lower than group 2(only flap+silicone) (47.93%) and group 4(saline+silicone) (45.65%) (p<0.001). Conclusion: Intradermal inactive platelet rich plasma administration decreases flap necrosis so for skin application.