Erol Benlier

Anthropometric Breast Measurement: A Study of 385 Turkish Female Students

BACKGROUND Anthropometric measurements and proportions of the human body have made a significant contribution to the science of aesthetic and reconstructive plastic surgery. OBJECTIVE The present study was performed to measure anthropometric breast values in Turkish female students and compare them with those of women in other nations. METHODS The study included 385 female undergraduate student volunteers between the ages of 18 and 26 years with no physical or developmental deformity and with a body mass index between 20 and 26. A total of 19 parameters were measured in a standing position. The parameters measured were body weight, height, shoulder width, upper chest width, middle chest width, lower chest width, waist width, hip width, clavicle-nipple length, sternal notch-nipple length, nipple-nipple length, upper arm length, medial mammary radius, lateral mammary radius, nipple-inframammary fold length, nipple diameter, areola diameter, nipple projection, and mammary projection. Breast volume, breast ptosis, and retracted nipple rates were also assessed. RESULTS The mean breast volume was determined to be 407.2 +/- 263.6 cc. The mean values of the right and left breast volumes were calculated as 415.2 +/- 264.5 cc and 399.1 +/- 265.5 cc, respectively; the right breast volume was significantly greater than the left breast volume (P < .001). The ideal external view of the breasts with equal volume for both sides and no ptosis was observed in 35.1% of the volunteers. The percentage of women with unilateral or bilateral retracted nipple was 2.6%. CONCLUSIONS The results of the present study will help in comparing the anthropometric breast values of young Turkish women with those of women in other countries. They may also be useful either in planning aesthetic and reconstructive breast surgery or in designing breast augmentation accessories and clothing.

Review of monitoring free muscle flap transfers in reconstructive surgery : role of 99mTc sestamibi scintigraphy

BackgroundFree tissue transfer is a method of moving any tissue from a donor area of the body to a recipient site and re-attaching the arteries and veins to the blood vessels at the recipient site by microvascular surgery. Improved microsurgical techniques have resulted in a high percentage of successful free tissue transfers. Post-operative monitoring of tissue viability can detect early problems in free tissue transfer which may allow early intervention and salvage. Although many flap monitoring methods have been described, there is still no consensus on which of these techniques will become the standard accepted method for monitoring free muscle flaps. ObjectiveIn present study, we investigated the use of 99mTc sestamibi scintigraphy in determining free muscle flap viability and complications, and also in directing treatment. MethodsThirteen patients were examined prospectively during the post-operative period after free tissue transfer for foot defects. The cause of the defect was diabetic foot ulcer in 10 patients, dermatofibrosarcoma in one patient, squamous cell carcinoma in one patient and gunshot wound in one patient. Foot defect covering was carried out with a free latissimus dorsi muscle flap and skin graft (n=12) and a free gracilis muscle flap (n=1). All patients were examined with a monitoring system that consisted of visual inspection, hand-held Doppler ultrasonography and scintigraphic examinations. Scintigraphic imaging of all cases was performed routinely within the first 48 h post-operatively, and also on days 10 and 91 in two patients. ResultsThere were four flap failures during the study. One of these patients had viable findings upon visual inspection and no evidence of vascular compromise on Doppler at the first examination. In the other patient, visual inspection of the flap showed that it was ischaemic in one region, but there was no vascular compromise on Doppler examination. Scintigraphic images of each of these patients showed a partial hypoperfused area in the flap region. Later, these two flaps showed positive clinical indications of hypoperfusion (colour of muscle and appearance of skin graft) and Doppler abnormalities. The remaining two patients had non-viable scintigraphic images as well as positive clinical indicators of hypoperfusion and evidence of vascular compromise on Doppler. Nine patients each had a viable flap. In these patients, all three examination tools demonstrated that the flaps were totally viable and there were no vascular complications. ConclusionAccording to the results of this study, 99mTc sestamibi scintigraphy appears to be a feasible and promising method in the evaluation of free muscle flap viability and complications. On the other hand, to demonstrate any impact on management or patient outcome, further evaluation of 99mTc sestamibi imaging, including comparative studies with different established methods in a larger patient population, is highly recommended.

Distally based sural flap in treatment of chronic venous ulcers.

The treatment of venous ulcers of the leg often fails to heal because venous ulcers are mostly associated with severe lipodermatosclerosis. These complicated ulcers may require correction of local hemodynamics, excision of ulcer with surrounding lipodermatosclerotic skin, and replacement of the defect with healthy tissue. We present our experience with the use of the distally based sural flaps for the reconstruction of soft-tissue defects of the distal region of the lower limb in patients with chronic venous ulcer. Between 2001 and 2003, 12 patients with venous ulceration were treated with distally based sural flaps. At operation, the ulcer and its surrounding lipodermatosclerotic skin were excised. The defects after excision ranged from 3 × 3 to 11 × 17 cm. The distally based sural artery flap was inset within the defect. In all patients, the flap survived completely, and in only 1 patient, distal venous congestion was seen and was treated successfully with leeches. There was donor site skin graft loss in 2 patients. Two flaps had minor local complications that healed with local wound care. No recurrent ulcers were identified after average 19.7 months. In conclusion, the distally based sural flaps can be used reliably for treatment of venous ulcers. Our approach in treatment of chronic venous ulcers improves venous hemodynamics and provides local flap alternative that should be considered prior to a free-flap transfer for closure of the defect.

An alternative procedure for conjunctivodacryocystorhinostomy: supratrochlear artery-based island flap combined with buccal mucosal graft.

Reconstruction of the total canalicular obstruction with destroyed medial canthal area is a challenging procedure for ophthalmic, plastic, and reconstructive surgeons. In the case presented, a supratrochlear artery--based island flap combined with a buccal mucosal graft was used for reconstruction of the medial canthal area. The medial canthal area was scarred significantly and demonstrated a medial ectropion and complete canalicular obstruction. To our knowledge, it is the first time for combined reconstruction of the medial canthal area and lacrimal drainage system in 1 stage, with island median forehead flap based on supratrochlear artery and buccal mucosal graft. During the 2-year follow-up period, no complication was encountered and the patient healed uneventfully.

Management of the Long Nose: Review of Techniques for Nasal Tip Supporting Structures

The long nose with a “plunging” tip is a deformity that involves an inferiorly rotated nasal tip, leading to an increase in the length of the nose. The anatomic basis of the long nose with a plunging tip may be divided into two types. Type 1 presents a normal alar–cartilage complex inferiorly displaced by a long nasal septum and long upper lateral cartilages. Type 2 is caused by a dislocation of the alar cartilages downward from the aponeurotic attachments to the septal angle. During the study period, the authors identified 60 patients with long noses and plunging tips. For 22 patients with type 1 long noses, the high septal incision technique was used in 12 cases and the step technique in 10 cases. The invagination procedure alone was used for 22 of 38 patients with type 2 plunging noses. Also, an extension graft with the invagination procedure was used for 6 patients, and a columellar strut graft was used for 10 patients. A high septal incision increased tip rotation without significantly changing the amount of tip projection. However, the step procedure, the invagination technique alone, septal extension graft with the invagination technique, and columellar strut grafts increased nasal tip rotation and projection. During the study period, 38 patients were identified as having a smiling deformity, which was improved using the authors’ modification procedure. On the basis of the results, the authors recommend that the appropriate treatment for each patient with a long nose and a plunging tip must be determined by preoperative and intraoperative examination findings with the patient at rest and while smiling.

A New Approach to Smiling Deformity: Cutting of the Superior Part of the Orbicularis Oris

A diagnosis of an aesthetic smiling deformity, which is functional rather than anatomic, is essential for provision of the best treatment in rhinoplasty. Smiling deformity consists of three elements: (a) the nasal tip tending to retrodisplace and rotate inferiorly; (b) the lower part of the upper lip moving superiorly; and (c) a horizontal groove occurring in the midphiltral area. An active depressor septi and orbicularis muscle can accentuate a drooping nasal tip and shorten the upper lip during smiling. Downward movement of the nasal tip and a sharper nasolabial angle usually are aesthetically unpleasant. During the study period (January 2000 to January 2004), the authors identified 38 patients with smiling deformities, 16 of whom underwent dissection and transposition of the paired depressor septi during rhinoplasty. The remaining 22 patients experienced hyperactivity of both the depressor septi and orbicularis muscles, as diagnosed by a descending nasal tip and a shortened upper lip at animation. These patients underwent a modification of the depressor septi and orbicularis muscles. No relapse was evident up to 2 years postoperatively. Repositioning of the depressor septi nasi muscle improved only mild cases. However, modification of the orbicularis and depressor septi muscles was a valuable adjunct to rhinoplasty for moderate and severe forms of smiling deformity. The new approach for smiling deformity provided an aesthetically pleasant appearance for the patient both at rest and when smiling.

Effect of lidocaine on reducing injury in a rat electrical burn model.

AbstractElectrical injuries induce progressive tissue loss. We evaluated the effect of lidocaine on tissue necrosis after electrical burn injuries. Forty-two male Wistar albino rats (250–300 g) were divided into 3 groups [Group A (n = 6), control group without an electrical burn injury; and Groups B (n = 18) and C (n = 18), electrical burn injury groups without and with lidocaine therapy, respectively]. Three separate analyses were performed at different time points on 6 of 18 rats from Groups B and C at each time point. Electrical burns were induced by applying 220 V AC between the left upper and right lower extremities for 10 seconds. Myeloperoxidase and malondialdehyde levels were measured in skin and muscle biopsy specimens after the first hour, fresh and dry weight differences in the amputated extremities were calculated after 24 hours, and live and necrotic tissue areas were measured at 7 days after burn injury. We found that lidocaine reduced edema, the number of neutrophils, and neutrophil damage in tissues. We conclude that lidocaine decreased the amount of necrotic tissue caused by electric injury.

Preventing graft loss caused by hematoma: experimental study.

Hematoma is a common reason for graft loss. This study was intended to investigate the effects of microporous polysaccharide hemospheres (MPH; Arista® AH; Medafor, Inc.) on graft survival, the effect of MPH on graft loss caused by hematoma, and the correlation between neutrophil accumulation and graft survival. A total of 35 adult male Wistar rats were separated into five groups of seven as follows: control 1, saline, MPH, control 2 (hematoma group), and MPH + hematoma. All graft dressing was removed on the fifth postoperative day and graft survival percentage measured. Histopathological and semiquantitative analysis, including inflammatory cell infiltration and subcutaneous inflammation based on neutrophil count, was performed. Graft survival significantly improved in the MPH group (97.86 ± 1.676) compared with the control 1 (91.14 ± 3.671; P = .004) and saline groups (91.57 ± 4.791; P = .014). There was no significant increase in graft survival in the saline group compared with the control 1 group or in the MPH + hematoma group (19.57 ± 14.707) compared with the control 2 group (20.71 ± 16.869; P > .05). The neutrophil count was highest in the control 2 group (177.43 ± 22.464) and significantly decreased in the MPH group (33. 71 ± 8,674) compared with the control 1 group (66.14 ± 5.872; P = .001) and the saline group (65.57 ± 3.309; P= .001). There was no significant decrease in neutrophil count in the MPH + hematoma group (160.00 ± 27.952) compared with the control 2 group (P > .05). It seems that MPH can increase the graft survival, and there is an inverse relationship between graft survival and neutrophil accumulation.

Depressor septi nasi modifications in rhinoplasty: a review of anatomy and surgical techniques.

The anatomy of the nasal muscles contributes a social harmony in aesthetic rhinoplasty because these muscles coordinate the nose and the upper lip while smiling. Sometimes this coordination can be interrupted by the hyperactivity or variations of these muscles and may result as a deformity because of their dynamic functions and relations with the nose. In our daily practice, we usually perform the rhinoplasty without considering the dynamic functions. When the patients recover the muscle functions after operation and start to use their mimics, such as smiling, the undamaged dynamic forces may start to rotate the tip of the nose inferiorly in a long-term period, correlated with their preoperative function. To avoid this unexpected rotation it is essential to remember preoperative examination of the smile patterns. To manage this functional part of rhinoplasty, we aimed to clarify the smiling patterns or deformities mainly focused on depressor septi nasi muscle in this article. This muscle creates downward movement of the nasal tip and shortens the upper lip during smiling. The overactivity of this muscle can aggravate the smiling deformity in some patients by a sharper nasolabial angle correlated with levator labii superioris alaeque nasi and orbicularis oris muscle activities. The article not only stresses the correction of this deformity, but also aims to guide their treatment alternatives for correlation of postoperative results and applicability in rhinoplasty.

Using Liposuction for Late Complication of Trachinus draco Envenomation

Trachinus draco (TD), a member of the Trachinidae fam-ily, lives near the eastern Atlantic coastline from Norwayall the way to Morocco, even in an area extending intoMadeira, Canary Islands, and the Mediterranean, Aegean,and Black Seas [1–3]. Literature on the late complicationsof TD envenomation is extremely limited [1, 3–6]. Wehave not found any publications in the English literaturethat report on the treatment of late complications fromTrachinus draco venom.A 35-year-old woman was referred to our Plastic Sur-gery Department because of swelling, pain, and limitedmotion of the right hand and index finger. She claimed thatshe had been stung by a weeverfish 3 years ago. Subse-quently, she had been treated for acute symptoms butswelling and pain persisted. On physical examination,subcutaneous edema of the dorsal aspect of the right hand,especially the index finger, was revealed (Fig. 1). Activeflexion movements of the index finger were restricted andmeasured 30 at the metacarpophalangeal (MCP) joint, 60at the proximal interphalangeal (PIP) joint, and 30 at thedistal interphalangeal (DIP) joint. The patient underwentlymphoscintigraphy for a differential diagnosis of differentpathologies. After interdigital injection of Tc99 m-anti-mony colloid there was normal visualization of theperipheral lymphatic channels in both upper extremities(Fig. 2). We could not find any pathology by ultrasonog-raphy in the axillary area.We performed liposuction on the dorsal aspect of thewrist under axillary anesthesia. We aspirated approxi-mately 60 cc of subcutaneous tissue which consisted of fattissue. Although the index finger still appeared edematous,both the edema of the dorsum and functions of the handwere improved after 6 months (Fig. 3) and 1 year (Fig. 4)(active flexion was measured as 80 for both MCP and DIPand 95 for PIP). No complication or recurrence occurredin the follow-up period.Trachinus draco lives on muddy, sandy, or gravellybases of the sea, in a depth ranging from a few meters toabout 150 m. It usually exposes the tip of the first dorsal finwhile resting on the sea bottom. The venom of the Tra-chinidae family, to which TD belongs, is a heat labileprotein called icthyoacanthotoxin. Besides this heat labileprotein, the venom also includes histamine, epinephrine,norepinephrine, and mucopolysaccharides [4, 7, 8].Trachinus draco-released dracotoxin has basically mem-brane-depolarizing and hemolytic properties. Envenoma-tion by weeverfish causes local symptoms at the site of thesting, such as pain, burning sensation, redness, and swell-ing. Several systematic symptoms such as fever, chills,vomiting, syncope, delirium, cardiac arrhythmias, andhypotension have been reported; however, death is rareafter envenomation by TD [2, 5–7]. The treatment for acuteenvenomation includes application of heat to the injuredsite [3]. Treatment of late complications of envenomationhas not been presented until now. Liposuction has been