Fatma Betul Tuncer

An anatomical variation of the MSAP flap: Single direct cutaneous perforator in the posterior calf region.

The medial sural artery perforator (MSAP) flap was first described by Cavadas et al. in 2001 (Cavadas et al., 2001) The popularity of the MSAP flap has been increasing since then, owing to its convenience for twoteam approach, low donor site morbidity, pliability, thinness, and reliable anatomy. Previous studies showed the distribution and branching pattern of musculocutaneous perforators in the cadaveric and clinical samples (Dusseldorp, Pham, Ngo, Gianoutsos, & Moradi, 2014; Hallock, 2001; Kao, Chang, Chen, Wei, & Cheng, 2010). However, to our knowledge, no direct cutaneous perforator taking its origin from the popliteal artery in the posterior calf region was reported in the literature. The patient was a 55-year-old male with a 6 cm 3 11 cm sized defect over the achilles tendon in the left leg. The surgical plan was made to reconstruct the defect with ipsilateral MSAP free flap. Prior to skin incisions, no perforator could be detected in the ipsilateral leg using a handheld Doppler device. Therefore, the contralateral leg was chosen for the flap harvest after the sound of a perforator was detected over the proximal part of the calf in the midline. The patient was placed in the supine position with the hip abducted, externally rotated, and the knee flexed. The initial incision was made along the medial border of the flap to confirm the location of the perforator. One intermediate sized perforator (1 mm in diameter) in the posterior midline which was accompanied with small saphenous vein (6 mm in diameter) was found. The dissection was carried out in cranial direction up to the popliteal artery without any intramuscular dissection between the medial and lateral heads of gastrocnemius muscle (Figure 1). Then, the incision on the lateral border of the flap was made. The perfusion of the flap had been confirmed as adequate before the pedicle was divided. The artery of the flap was anastomosed to the posterior tibial artery in end-to-side fashion, whereas the great saphenous vein, transposed to the recipient site, was anastomosed to the vein in end-to-end fashion. The donor site was closed using skin graft. The postoperative course was uneventful. The location, size, number of perforators as well as anatomic variation of perforators in the calf region were studied previously (Cavadas et al., 2001; Dusseldorp et al., 2014; Hallock, 2001; Kao et al., 2010). Overall, most of the perforators found in the posterior calf region are located on the medial side and the mean number of perforators range from 2.0 to 2.7 in these studies (Cavadas et al., 2001; Dusseldorp et al., 2014; Kao et al., 2010). A major medial sural artery perforator was present in 98% of dissection specimens (162/166) reported in the literature (Dusseldorp et al., 2014). In the present case, no sizable perforator was found over the medial or lateral gastrocnemius muscle but a midline direct cutaneous perforator was present. For the perforator-based flaps, anatomic anomalies tend to be the rule, not an exception (Hallock, 2007). The location, size, and number of the cutaneous perforators greatly vary between the individuals, and even between the two sides of the body. The surgeon must be prepared for altering the location and orientation of the MSAP flap according to the perforator, and even for proceeding to an alternate donor site if an adequately sized perforator cannot be found.

Ameloblastoma in a Patient With Williams Syndrome and Use of Fibular Flap

Williams syndrome (WS, also known as Williams – Beuren syndrome) is a genetic disorder caused by a deletion of large gene locus at chromosome 7q11.23. Its incidence is estimated from 1 in 20,000 to 1 in 50,000. Williams syndrome is characterized by supravalvular aortic stenosis, dysmorphic facial features, teeth abnormalities, neurodevelopmental delay, learning disabilities, and excessively friendly personality. The genetic deletion that is well defined in WS is currently not considered a risk factor for cancer development. However, more than 15 cases of malignancy were reported in patients with WS. Here, we described a unique case of WS diagnosed with a mandibular ameloblastoma, its surgical management and successful reconstruction with a vascularized fibular flap. To our knowledge, this is the first report of WS associated with ameloblastoma and first report of free flap reconstruction in a patient with WS in the literature.

Assessment of Tissue Perfusion Following Conventional Liposuction of Perforator-Based Abdominal Flaps

Background The effect of liposuction on the perforators of the lower abdominal wall has been investigated in several studies. There are controversial results in the literature that have primarily demonstrated the number and patency of the perforators. The aim of this study was to determine the effect of liposuction on the perfusion of perforator-based abdominal flaps using a combined laser–Doppler spectrophotometer (O2C, Oxygen to See, LEA Medizintechnik). Methods Nine female patients undergoing classical abdominoplasty were included in the study. Perforators and the perfusion zones of the deep inferior epigastric artery flap were marked on the patients abdominal wall. Flap perfusion was quantitatively assessed by measuring blood flow, velocity, capillary oxygen saturation, and relative amount of hemoglobin for each zone preoperatively, after tumescent solution infiltration, following elevation of the flap on a single perforator, and after deep and superficial liposuction, respectively. Results The measurements taken after elevation of the flap were not significantly different than measurements taken after the liposuction procedures. Conclusions The liposuction procedure does not significantly alter the perfusion of perforator-based abdominal flaps in the early period. The abdominal tissue discarded in a classic abdominoplasty operation can be raised as a perforator flap and has been demonstrated to be a unique model for clinical research.

Oral Reconstruction Using Medial Sural Artery Perforator Flap in a Patient With Fanconi Anemia.

DISCUSSION Osteochondroma is a cartilagineous lesion. The true nature of the process, whether developmental, reactive or neoplastic, is unknown. It is thought that the proliferating cartilage cells may derive from displaced epiphyseal cartilage cells, from stimulated mesenchymal cells of tendinous insertions, or from pluripotent periosteal cells. An unusual feature of the patient herein presented is the presence of a relatively small lesion at the basis of the osteochondroma showing the features of the compact variant of an osteoma. Solitary osteomas of the jaw are rare, mostly occurring on the lingular aspect of the mandibular angle but may also involve the coronoid process or condylar notch. It can therefore be suggested that the osteochondroma in the present patient is reactive in nature, due to the presence of the underlying osteoma. The aetiology of progressive limitation in oral opening can arise from extraor intra-articular pathology. The presence of an intraarticular pathology, like chronic temporomandibular joint disk displacement, can lead the clinician to neglect Jacob disease when the 2 conditions coexist in the same patient. Therefore, we recommend a radiographic study: a screening panoramic radiograph can show enlargement of the coronoid processes, and magnetic resonance imaging can rule out internal derangement and joint pathology; computed tomography can confirm the absence of temporomandibular joint ankylosis and will clearly show coronoid enlargement. Coronoidectomy is the definitive treatment for Jacob disease. According to our experience, advantages such as direct vision, easy and safe osteotomy control, minimal risk of damage to the medial tissue, bloodless operatory field, fast surgery, and brief hospitalization can be obtained using endoscopically assisted intraoral coronoidectomy. When exostosis is bulbous and large, such as in our patient of a mushroom-shaped lesion, reconstruction of a deformed zygoma with a calvarial bone graft is required, or a bilateral condition exists, we recommend a coronal or an emicoronal approach. The latter approach guarantees a good view of the surgical field and results in an acceptable scar behind the hairline; but the risk of damage to the facial nerve remains. Based on the authors’ experience, during the osteotomy, the best control and maximum cutting precision can be achieved using the ultrasonic bone-cutting technique.

Nasopharyngeal Placement of a Nelaton Suction Catheter in Respiratory Monitoring of Sedated Patients

Office-based cosmetic surgeries, which utilize mild to moderate sedation in addition to local anesthesia, are frequently performed both in the United States and European countries. Statistics released by the American Society for Aesthetic Plastic Surgery showed that 56% of all cosmetic surgeries performed in 2014 were in the office setting.1 The growth of office-based cosmetic procedures raises the risk of rarely seen sedation-related adverse events. Sedation at any level beyond minimal has a risk of ventilatory depression and airway obstruction, which can result in anoxic brain injury and death. Although the intention is to maintain the same level of sedation during procedures, there is always risk of progressing to a deeper level of anesthesia. One study that assesses sedation levels at 3-minute intervals during elective endoscopy procedures showed that deep sedation occurred at least once in 68% of their patients who were intended to undergo moderate sedation.2 Respiratory monitoring has two components: oxygenation and …

Acute Liver Failure and Hepatic Encephalopathy After Cleft Palate Repair.

Paracetamol is the most commonly used analgesic after cleft palate repair. It has rarely caused acute hepatic failure at therapeutic or supratherapeutic doses. Only one case of therapeutic paracetamol toxicity after cleft palate repair had been reported previously. Here, we present a similar patient who developed acute liver failure and hepatic encephalopathy after an uncomplicated cleft palate surgery. Lack of large prospective trials in young children due to ethical concerns increases the value of the case reports of acetaminophen toxicity at therapeutic doses. The dosing recommendations of paracetamol may need to be reconsidered after cleft palate surgery.

An Unusual Deformity of the Nose: Medial Crural Fracture.

Even though we have a full craniofacial surgical set, we sometimes use sterile metal tablespoons for these purposes. We use different sizes of sterile spoons, and we have them as an addition to our set. Larger sizes are especially useful in intraoral tissue retraction. They provide better view with wide area protection of the cheek mucosa and the tongue especially during interdental wiring and splints. Smaller sizes could be used as globe retractors since they provide better exposure than the classic quadrangular globe retractors. Their concave sides have proper sitting surface for the convexity of the globe (Fig. 1). Although they are not professional surgical instruments they are cheap, effective, and could be found easily in the market. We have observed fewer amounts of postoperative complaints such as mucosal tears or labial edema from the patients after surgery. We confidently recommend this instrument especially in the previously mentioned indications to our colleagues.