Gökhan Temiz

Free-tissue transfers for reconstruction of oromandibular area in children.

Introduction: Currently, free‐tissue transfers are commonly used for various reconstructive purposes in adults. However, there is a lack of large series of free flap reconstruction in children, especially for reconstruction of oromandibular defects. Our study aims to share our experience in free‐flap reconstruction of some challenging pediatric cases. Materials and methods: Pediatric free‐flap interventions (<18‐year‐old) that were performed between 2000 and 2006 in our clinic were retrospectively evaluated. Eighteen free‐tissue transfers were performed in 17 pediatric cases. Epidemiologic data, etiology, defects, preferred free flaps, and results have been compared and analyzed. Results: A total of 17 patients (18 free flaps) were analyzed. Mean age was 10.4 years. The etiology was tumor in 11 cases, traffic accident in 5 cases, and gunshot in 1 case. Double‐flap transfer was performed to one patient with a devastating shotgun wound and single flap transfers to others. A total of 8 osseous flaps, 7 osteocutaneous flaps, and 3 septocutaneous flaps were transferred. Total superficial flap necrosis was encountered in one flap (5.8%) while partial superficial necrosis was seen on two flaps (11.7%). Sixteen of the 17 cases reconstructed, including the three cases with complications, resulted in good functional and cosmetic outcome. One case was lost in the sixth postoperative month due to septisemia during chemotherapy. All the surviving 16 cases acquired bony fusion, mastication, and speech in addition to good cosmetic results. Conclusion: Pediatric free‐tissue transfers are increasing due to the development of better equipment, finer surgical technique, and a better understanding of the unique characteristics of pediatric cases. In our opinion, high success rates with good cosmetic and functional results can be obtained if the specific requirements of the pediatric procedures are met.

A New Option for the Reconstruction of Orbital Floor Defects: The Olecranon Bone Graft.

BackgroundOrbital floor fractures are one of the most commonly encountered maxillofacial fractures due to its weak anatomic structure. Autogenous bone is a commonly used option for the reconstruction of orbital floor defects by many authors and institutions. This article introduces the olecranon bone graft as a new option for orbital floor reconstruction. MethodsThe study is based on the analysis of 13 patients with orbital floor fracture operated on by using the olecranon bone graft. The mean age of the patients was 34 years 6 months. The physical examination of 5 (38.5%) patients revealed diplopia, 3 (23%) patients gaze restriction, 3 (23%) patients infraorbital nerve paresthesia, and 7 (53.8%) patients enophthalmos with various degrees. The mean defect size was 21.15 × 14.08 mm and the mean defect field was 2.98 cm2. All patients were operated on under general anesthesia and the orbital floor defect was exposed subperiosteally. The olecranon bone graft was harvested in 10 cases using a 3-cm incision over the olecranon and in 3 cases using the bone biopsy trephine and placed to the orbital floor defect after shaping with cottle cartilage crusher. Both clinical and radiological follow-up examinations were carried out in the postoperative period. ResultsThe mean follow-up period of the patients was 7.92 months. The mean size of the grafts was 24.85 × 17.54 mL. The mean field of the grafts was 4.26 cm2. Among the 7 patients who had enophthalmos before the surgery, complete resolution was observed in 6 (85.7%) patients and in the remaining 1 (14.3%) patient, the degree of enophthalmos was found to be significantly reduced at the postoperative sixth month examination. All patients with preoperative diplopia and gaze restriction showed complete healing in the postoperative period. Eleven (84.6%) patients showed mild pain at the olecranon donor area with complete relief in the postoperative 3 days and the remaining 2 (15.4%) patients had moderate pain sensation which completely passed away at the postoperative fifth day. ConclusionsThe olecranon bone graft is a suitable autogenous option for orbital floor reconstruction due to its considerable strength and molding capacity with low rates of complications and donor area morbidity.

Extradigital glomus tumor revisited: Painful subcutaneous nodules located in various parts of the body

Background: Glomus tumor is a common lesion of the subungual area of the hand fingers. However, glomus tumors located outside the hand region are rare and the diagnosis is often difficult due to their low incidence and lack of distinct clinical features in the physical examination. The presented article contains five cases of extradigital glomus tumors with a short review of the literature. Patients and Methods: Five cases of extradigital glomus tumor were included in the study. All lesions were purple colored subcutaneous nodules with sharp pain by digital palpation. All lesions were examined with ultrasound imaging were operated under local anesthesia using loupe magnification. Results: Among five patients, only one patient was female with a mean age of 35. Two lesions were located at the arm region, two at the crural region and one at the sternal area. The smallest nodule was 0.5 cm and the biggest lesion was 2 cm in diameter. In all the cases, the early postoperative period was uneventful without any surgical complication or acute recurrence. The postoperative 1st year examination of all patients revealed complete resolution of the pain and no recurrence was encountered. Conclusions: Glomus tumor should be kept in mind in the differential diagnosis of all painful subcutaneous lesions especially for those with purple reflection on the skin surface. In this manner, patients with extradigital glomus tumors may be diagnosed earlier and unnecessary and wrong treatments may be prevented.

The lever technique for the external reduction of temporomandibular joint dislocation

Temporomandibular joint (TMJ) dislocation usually occurs due to large bites, yawning, laughing, neuromuscular diseases, dental operations or intubation in sporadic, recurrent or chronic recurrent fashion. In the acute period, closed reduction maneuvers with the support of a muscle relaxant medication are usually useful for the treatment. In classical closed reduction maneuvers, the displaced condyle head is moved backward and downward along the articular eminence of temporal bone and returned back into the glenoid fossa. Most of these methods are performed with an intraoral approach by placing both thumbs over the third molar teeth in both sides and pulling the angles of mandible downwards using the remaining four fingers to overcome tractional forces of masticatory muscles. This article presents a new technique used for the closed reduction of TMJ dislocations extraorally which offers both the physician and the patient an easier and safer reduction. Twenty-nine patients; twenty-one with unilateral TMJ dislocation and the remaining eight with bilateral dislocation were included to the study. The mean patient age was 32,6 years in a range of twenty-four to forty-four and twenty patients were female while nine of them were male. The etiologic reasons of the TMJ dislocations were yawning while asleep in fourteen patients, followed by large bites in six patients, dental operations of third molars in five patients and laughing in three patients. All patients had severe pain at the effected TMJ and periauricular region and were unable to close their mouth while patients with unilateral dislocation experienced also latherognathia. In all patients, plain radiographs of the head and TMJ were taken both for the confirmation of the dislocation and evaluation of the pericondyler bone deposition of the patient.

Congenital isolated aplasia of lower lateral cartilage and reconstruction using dorsal hump material.

Congenital nasal abnormalities are very rare in the literature. There are 3 reported cases of isolated partial lower lateral cartilage defects. In this article, we report the case of a patient with congenital complete absence of the lower lateral cartilage. The patient had severe external nasal valve dysfunction and a concavity of the alar vault, even in the resting position. The defect was reconstructed using resected and reshaped nasal dorsal hump material. At the end of a 12-month follow-up period, the patient was satisfied with the functional and aesthetic results of the operation. No external or internal nasal valve collapse occurred during inspiration. Such developmental abnormalities may be syndromic and require special attention for reconstruction.

A useful option to obtain maximal foreign body removal and better prognosis in high pressure injection injuries: Negative pressure wound therapy with instillation

High pressure injection injuries to the hand are quite rare and they should be evaluated as a surgical emergency. Delay in the diagnosis and treatment usually occur if high pressure injection injuries does not present with an emergent clinical situation such as compartment syndrome. The prognosis depends on the features and the volume of the injected substance but it should be stated that amputation rates up to 48% were reported in previous publications. All foreign substances should be removed and copious irrigation in conjunction with debridement of all necrotic tissues should be performed. We present a useful technique including the utilization of vacuum therapy to remove maximum possible foreign body after adequate debridement as a preliminary study. Five patients with high pressure dye injection injuries treated between years 2011e2014 were presented in the paper (Table 1). The average age of the patients was 35,8 and the entry wounds of two patients were located in the palmar area, three patients in the volar surface of the fingers. In all patients, immediate debridement was performed and negative pressure wound therapy (NPWT) with instillation (wound irrigation) was applied to the open wound area with a mean pressure of 50 mmHg initially to prevent any possible obstruction of neurovascular bundles and circulatory problems. The pressure was increased to 75 mmHg in the postoperative first day, 100 mmHg in the postoperative second day and 125 mmHd in the postoperative third day. If no sign of circulation problems were encountered, NPWTwas continued with 125 mmHg pressure for the remaining days of the treatment. The extremity was

Hezarfen wings: a lower lateral cartilage-based cartilage suspension technique for the adjustment of nasal tip rotation and projection and the correction of supratip deformity.

AbstractNasal tip surgery is one of the most important parts of rhinoplasty to achieve an attractive nose. There are numerous techniques focusing on the correction of nasal tip rotation and projection. In this article, a new cartilage support derived from the cephalic border of lower lateral cartilages is used for the adjustment of tip rotation and projection, whereas improving supratip fullness is presented. Bilaterally harvested cartilage extensions are resembled as bird’s wings and dedicated to the wings that were created by the world’s first scientist who flew from one continent to another: Hezarfen Ahmed Çelebi.Thirty-two patients who underwent open-approach rhinoplasty operation including the abovementioned method were evaluated retrospectively. After performing conventional steps of open approach rhinoplasty, a wing is created by making a cephalic incision parallel to the lateral crural axis leaving the medial attachment intact and then undermined. Then, the cartilage is turned over the midline bilaterally as it acts like a curb by pulling or releasing the wings to adjust to the desired tip rotation and projection and sutured to the repaired upper lateral cartilage roof. Other 2 types of using these wings were asymmetric suturing one of the wings to help in the redirection of deviated nasal tip (n = 12) and suturing each other at midline to support the overlying skin like a tent with supratip deficiency (n = 7).The authors presented here both esthetic and functional outcomes of Hezarfen wings’ method that was used for both nasal tip adjustments and supratip support.

A useful device for the improvement of maximal interincisor opening after operations of temporomandibular region: the clothes PEG.

To the Editor: Range of motion exercises are essential for a functional temporomandibular joint (TMJ) after TMJ and mandibular condyle or subcondyle fracture operations as well as for the management of trismus secondary to head and neck cancer radiotherapy. Several devices and exercise methods were reported, such as the step-by-step increasing maximal interincisor opening (MIO) with stacked tongue depressors, range of motion devices such as TheraBite System (TheraBite Corporation, West Chester, PA), hotpack plus massaging before unassisted closing and opening exercises as used in Duchenne muscular dystrophy, and custom-made dynamic bite openers. As an alternative to such training methods, we used clothes pegs for the improvement of MIO. We used this device in 16 patients for TMJ range of motion exercises. The mean patient age was 18.2 years (range, 7Y33 y). Nine patients had cases secondary to maxillomandibular fixation after mandibular condyle and subcondyle fracture surgery, whereas 7 patients had cases that were caused by TMJ ankylosis surgery. The cases of 5 patients with TMJ ankylosis were unilateral, whereas 2 of them were bilateral. The patient with these cases underwent silicone gap arthroplasty operation, followed by range of motion exercises that started at the fifth postoperative day. Mean MIO was 1.9 cm (range, 0.9Y2.3 cm) before and 5.1 cm (range, 4.4Y5.6 cm) 3 months after the training started. The patients were followed up for 6 months after the beginning of exercises.At the end of the fourthmonth, increases inMIO reached the plateau. All of the patients were satisfied from the exercises. There were no ‘‘device-related’’ complications. The cloth holder end of the peg is inserted to the interincisor opening, and passive opening-closing exercises are performed with gradually increased peg opening (Fig. 1). Also, the reverse end of the clothes pegmay be used for static gradual opening of the interincisive opening (Fig. 2). In this case, the cloth holder end of the peg is opened manually until the opposite arms of the opposite ends are in contact together. Then, it is inserted to the interincisive area and held in place for 2 minutes at the beginning of the exercise. Exercise time is increased gradually, with 15 minutes of resting intervals. Our investigation of different manufacturers of clothes peg revealed that the maximal load of the holder ends ranges from 0.75 to 4 kg. These amounts are thought to be enough for TMJ exercises. In 2 patients with bilateral TMJ ankylosis, double clothes pegs were inserted between the lateral incisors bilaterally for training to provide more force. However, a specialized range of motion devices is useful for TMJ training; they are expensive and unavailable in many countries as stated by Kamstra et al. Clothes pegs are cheap, accessible, and useful alternatives to such devices. Both dynamic and static exercises are available with clothes pegs. The main restriction of these devices is the shorter length of domestic clothes pegs as compared with other dynamic devices. Therefore, patients may get tired shortly after the beginning of training. However, longer clothes pegs that are used in cloth cleaning centers or other industrial companies may be available to overcome this problem. Although we do not have any experience in trismus due to radiotherapy, double clothes pegs may be used in such patients. As a static range of motion device, clothes pegs may be used for home exercises in these patients. In our opinion, clothes pegs are useful, accessible, and cheaper alternatives to conventional dynamic exercise devices. Our team is also studying on different articulated home-type devices such as cake holders, forks, and strong buckles that may be used for the same purpose. Results will be reported soon.

Effects of Deferoxamine on Fat Graft Survival

The most important problem in fat transplantation is the unpredictable rates of resorption. Deferoxamine (DFO) is an iron-chelating agent with many useful functions including stimulating angiogenesis and antioxidant nature. The purpose of the study is to evaluate the effects of DFO on fat graft viability in rat model. A total of 24 Wistar rats were divided into three groups and 0.5 g of the left inguinal fat pad was extracted. In control group, fat grafts were implanted to the parascapular area without performing any procedure. In sham group, they were implanted in 0.2 mL saline solution followed by serial saline injections for 1 month. In the study group, fat grafts were implanted in 0.2 mL saline solution and 300 mg DFO followed by serial DFO injections for 1 month. At the postoperative second month, fat grafts were taken back and sent for histopathologic examination. The weight measurements of biopsy specimens in the study group demonstrated significantly higher than in the other two groups. Inflammation and fibrosis rates were also found to be significantly higher in the study group compared with the other groups; however, no significant difference in the apoptosis rates was detected between the groups. Fat grafts enriched with DFO showed significant increase in fatty tissue content in the study group compared with the control and sham groups. DFO increases the fat graft survival in rats and it may be a useful addition in autologous fat grafting procedures to increase fat graft viability and obtain maximal long-term durability.

Facial Artery Perforator and Depressor Anguli Oris Muscle Chimeric Flap: A New Design of an Old Flap.

BackgroundThe aim of this study was to investigate the reliability and outcomes of the facial artery perforator and separately elevated depressor anguli oris (DAO) muscle chimeric flap for the reconstruction of partial or total lower lip defects. MethodsEleven patients with malignant skin tumors located at the lower lip were operated between 2013 and 2015. After the excision of the tumor with adequate clear margins using margin controlled excision technique, an appropriate flap fitting to the resultant defect based on the perforators of the facial artery and DAO muscle was prepared and placed into the defect. The DAO muscle activity was tested with electromyography in the postoperative first year examination. ResultsBesides 1 patient with transient venous insufficiency, all the flaps healed well without a partial or total flap loss. The mean follow-up period was 10 months. No new primary tumor or recurrence was observed. Although in 1 patient, transient asymmetric smiling and mild drooling was observed, the overall oral competence results were found to be quite satisfactory. The electromyography evaluation of DAO muscle of 5 patients who reached the postoperative first year examination showed action potential results in normal limits with a slight decrease. All patients were satisfied with the final esthetic and functional result. ConclusionsThe facial artery perforator and depressor angel oris muscle chimeric flap is a valuable option for reconstruction of lower lip defects providing esthetically and functionally good results.