Ilker Yazici

Maxilla Allograft for Transplantation : An Anatomical Study

Introduction:The aim of this study is to present an anatomic study and a dissection technique to prepare maxilla graft for transplantation. Methods:Six fixed adult human cadavers were used for dissection of the maxilla grafts. Retrospective reviews of archives of 10 MRI and 5 angiographies of the maxillary region were performed to demonstrate the vascular and soft tissue anatomy of this area. Results:We have harvested maxilla graft as a single unit (larger type of Le Fort II) based on arterial and venous pedicle ready for transplantation. MRI evaluation revealed the vascular structures in the masticatory space and its anterior pterygomaxillary extension. Angiographic observations have demonstrated the arterial blood supply of the maxillary region, which lies within the pterygomaxillary region that we have included in the graft. Conclusions:We are presenting a method for harvesting of the maxilla graft, with vascular supply based on certain anatomic landmarks.

A rare complication of nasotracheal intubation: accidental middle turbinectomy.

In this paper, we are presenting a rare case of accidental middle turbinectomy, a complication of nasotracheal intubation. We have reviewed the literature and addressed important parameters on nasotracheal intubation to avoid damage to the turbinates and its possible serious complications.

Specimen Radiography: An Assessment Method for Reduction Mammaplasty Materials

Abstract. Although, one out of every eight women has a risk of developing breast cancer, the reported incidence of breast carcinoma detection in reduction mammaplasty materials is rather low. To our knowledge, specimen radiography, which is used for breast biopsies has not been used for the assessment of breast reduction materials. We investigated the applicability of specimen radiography and its potential benefits in detection of the breast pathologies, especially malignancies in reduction mammaplasty materials. Forty patients scheduled for reduction mammaplasty operation were included. In all cases an inferior pedicle reduction technique was preferred and the radiographs of the resected breast tissues were taken immediately. The radiographs were evaluated for any possible pathologic appearance and all abnormal findings were marked. For the histopathologic evaluation, in addition to the random sampling of the pathologist, any marked areas were also microscopically examined. In two cases fibrocystic changes were found in radiographs and the same results were obtained in the histological examination. No false negative mammogram was seen. Specimen radiography, which is applicable for breast reduction materials is an easy and cheap method and does not cause any patient discomfort. It seems that the radiographs of reduction mammaplasty materials are useful to provide guidance to the pathologist during tissue sampling for microscopic examination especially when large amounts of breast tissue is excised.

Enophthalmos due to atelectasis of the maxillary sinus: silent sinus syndrome.

Silent sinus syndrome is a clinical entity with the constellation of progressive enophthalmos and hypoglobus due to gradual collapse of the orbital floor with opacification of the maxillary sinus, in the presence of subclinical maxillary sinusitis. It occurs secondary to maxillary sinus hypoventilation due to obstruction of the ostiomeatal unit. In this paper, a 35-year-old woman with a complaint of asymmetry in her left eye and denting of upper eyelid was reported. In the left eye, upper sulcus was deepened and there was 3-mm hypoglobus. There was no diplopia or restriction of eye movements in any gaze positions. Hertel exophthalmometry revealed a 4-mm enophthalmos on the left eye. Computed tomographic scan of the orbita and paranasal sinuses showed left maxillary sinusitis, air-fluid level, and collapse of left maxillary sinus walls. In addition, inferior bulging in the left orbital floor was also reported. The treatment was a 2-stage operation. In the first stage, she underwent endoscopic septoplasty plus left maxillary antrostomy, and in the second stage, she underwent a subciliary orbital floor repair of the iliac bone resulting in the improvement of the enophthalmos and her cosmetic appearance. Regarding this case, the literature is also reviewed in detail.

Microsurgical training model for lymphaticovenous anastomosis in rat

Microsurgical training in rat models has been accepted as a vital step in educational process of achieving microsurgical skills? Currently, adequate and unique training models have been established for microsurgical dissection techniques, arterial and venous anastomosis as well as nerve repair and grafting techniques. These models have been developed in rats and include following applications: 1) the femoral and carotid arteries for arterial anastomosis trainning, 2) the femoral and jugular veins for venous anastomosis training, 3) sciatic nerve for coaptation for nerve repair trainning. These models can be extended for different technical applications such as end-to end, end-to-side, and sleeve anastomosis and interpositional vein grafting techniques. These techniques allow to build basic skills which are required to practice reconstructive microsurgery hand surgery, peripheral nerve surgery, and neurosurgery. Lymhaticovenular or lymphaticovenous anastomosis technique have revolutionarized the lymphoedema surgery by providing new approach for some difficult cases. This intervention is known as a ‘‘supermicrosurgical’’ technique and is considered as quite esoteric and unique microsurgical application due to low incidence of cases requiring such skills and due to lack of technical experience and expertise. Although these cases are not so commonly encountered by regular microsurgeon we believe that technique of lymphaticovenous anastomosis should be introduced in regular microsurgical training to prepare microsurgeons who can handle complex microsurgical reconstructions to be able to incorporate lymphatic vessel anastomosis if required. To fill this gap in microsurgical training we are presenting here a new training model for lymphatic vascular dissection and lymphaticovenous anastomosis in rat. We have used five Wistar rats in which we have dissected, and exposed thoracic duct and performed end to end anastomosis (two rats) to anterior facial vein and end-to-side anastomosis (three rats) to external jugular vein. During our dissections, surgical approach to thoracic duct in rat was a challenging step of the procedure, especially for a novice microsurgeon, thus it should be taken with caution involving following steps: Step 1: left side longitudinal skin incision starting from the mandible and extending to thorax. Step 2: excision of structures such as left submandibular gland, left sternocleidomastoid, and omohyoid muscle as well as the left clavicle. During these two steps, particular attention must be payed to meticulous dissection and retracting the branches of the external jugular vein within the neck fascia to prevent bleeding and opening of the external jugular vein. Step 3: identification of the subclavian vein and thoracic duct junction medially. Step 4: identification of common carotid artery. Step 5: following with sharp dissection from the thoracic duct–subclavian vein junction (lies adjacent to strap muscles overlying trachea) to the area just anterolateral to the carotid sheath (upper segment). After identifying the junction of thoracic duct and subclavian vein we had observed the physiological reflux of blood pulsating from the subclavian vein to the thoracic duct. During dissection white hue of the brachial plexus fibers were visible under the neck fascia. After ex*Correspondence to: Ilker Yazici, M.D., Kirikkale Üniversitesi Tip Fakültesi, Plastik Cerrahi Anabilim Dali Saglik Sok. Fabrikalar Mah, 71100, Kirikkale, Turkey. E-mail: ilkeryazici@gmail.com

Topographical anatomy of the dorsal branch of the ulnar nerve and artery: a cadaver study

PurposeThe surgical anatomy of the dorsal branch of the ulnar nerve and artery on the dorsal aspect of the hand is important in design of neurocutaneous flaps for reconstructive surgery and serves as a donor site for nerve grafts. In this study, the course, location, and diameter of the dorsal branches of the ulnar nerve and artery were studied from anatomical and reconstructive perspectives.MethodsUpper limbs of 14 (7 left and 7 right) and 22 formalin-preserved adult cadavers (15 left and 7 right) were dissected in two different centers.ResultsThe diameters of the ulnar nerve, artery, and their dorsal branches were measured at selected reference points. The distances to specific anatomical landmarks were also measured, during their courses from the proximal forearm towards the middle phalanges of the 4th and 5th fingers.ConclusionsOur data may facilitate the design of neurocutaneous flaps nourished from the dorsal branches of the ulnar nerve and artery, and may aid in the harvesting of nerve grafts from the dorsal branch of the ulnar nerve, and provide a safe surgical approach to the dorsum of the hand.

The use of tissue expander in the management of staged proximal hypospadias repair: report of case

Multiple failed hypospadias reconstructions may cause minimal residual skin, as a result of extensive scarring. However, extragenital full thickness skin grafts or mucosal grafts are often used for urethral substitutions; local tissue expansion can provide additional matched skin, which can be easily harvested and used for penile constructions. Though tissue expanders were used as the choice of treatment in children with multiple failed hypospadias repairs, the use of tissue expander in the management of staged proximal hypospadais repair has not been reported previously. A 3-year-old boy with proximal hypospadias is presented to discuss the use of tissue expansion in the management of staged proximal hypospadias repair.

Methylene blue vital staining of nerve stumps in secondary peripheral nerve repair.

Adequate preparation of the nerve stumps prior to nerve coaptation or grafting is vital for obtaining satisfactory results in secondary peripheral nerve repairs. Resection of the posttraumatic neuroma is needed in order to get rid of the blocking fibrosis and reaproximate axonal tubes. Freshing the nerve edges and resection of the neuroma must be performed with precision in order to minimize the nerve gap and to reach healthy axonal tubes (preinjury segment). Well trained surgeon familiar to peripheral nerve structure and adequate magnification is needed for this purpose. As a secondary aid and a novel approach we are using vital methylene blue staining in order to confirm and documentize that we have reached the healthy nerve structure. Vital staining of nerves by methylene blue was first demonstrated by Ehrlich and used for research purposes and surgical purposes up to date. Intraoperative surgical vital staining of peripheral nerves with methylene blue was found to be an effective method in order to identify complex nerve structures for sparing during extensive procedures. Facial 2. Enables documentation of the surgical session and the extent of the injury by taking photos for legal purposes. 3. Enables documentation of healthy axons if exists in the case of neuroma in continuity for correlation with preoperative Fig. 1. Sequential photos of nerve slices starting from the tip of the stump. From slice-a to d intraneural fibrosis (depicted with arrow) diminishes. Arrow shows very little amount of fibrotic tissue persistent in slice-d. Slice-a includes no fascicular structure stained whereas slice-d reveals healthy fascicular structure.

Use of triangulation method in end-to-side arterial microvascular anastomosis.

In this article, we present the use of triangulation for end-to-side microvascular arterial anastomosis. The classic end-to-side anastomosis starts by putting 2 sutures 180 degrees apart to the lateral arteriotomy aperture that is parallel to the longitudinal axis. We are performing triangulation in end-to-side microvascular artery anastomoses by putting 3 stay sutures, securing 2 of them to visualize vascular lumen and reduce the risk of passing suture from the back wall. We have been using this method for the last 5 years and found that triangulation seems to be a safer technique to teach and practice end-to-side microvascular anastomosis.

The effect of penile urethral fat graft application on urethral angiogenesis

BACKGROUND Autologous fat grafts are rich in adipose-derived stem cells, providing optimal soft-tissue replacement and significant quantities of angiogenic growth factor. Although fat grafts (FG) are used in several clinical conditions, the use of FG in urethral repairs and the effects of FG to urethral repairs have not yet been reported. OBJECTIVE An experimental study was performed to evaluate the effect of FG on urethral angiogenesis and tissue growth factor (GF) levels. STUDY DESIGN Sixteen Wistar albino, adult, male rats were allocated into two groups: the control group (CG) (n = 8) and the experiment group (EG) (n = 8). After anesthetization of all rats, 3-mm vertical incisions were made on the urethras, and then sutured with interrupted 5/0 vicryl sutures. The operations were performed under a stereo dissecting microscope under magnification (×20). In the CG, no additional procedure was performed. In the EG after the same surgical procedure, 1 mm(3) FG was removed from the inguinal region by sharp dissection with a knife. The grafts were trimmed to 1 × 1 mm dimensions on millimeter paper. The FGs were placed on the repaired urethras. The skin was then closed. Samples from urethral and penile skin were taken 21 days after surgery in both groups. Density and intensity of staining with vascular-endothelial GF (VEGF), VEGF-receptor, and endothelial-GF receptor (EGFR) in the endothelial and mesenchymal cells of the penile urethral vessels were immunohistochemically evaluated. Data obtained from immunohistochemical evaluations were analyzed with SPSS 15.0. The P-values lower than 0.05 were considered as significant. RESULTS Density of VEGF staining was significantly decreased in the vascular endothelium of the EG compared to the CG (P < 0.05). Density of the EGFR staining was significantly decreased in the vascular endothelium of the EG compared to the CG (P < 0.05) (Table). Intensity of VEGF, VEGF-R and EGFR staining was not significantly different between the two groups. There were no significant differences between groups regarding to VEGFR staining and mesenchymal examination. DISCUSSION Decreased density was found in the VEGF staining in the vascular endothelium. This could be explained by the day that the tissues were harvested or because autologous fat grafts might cause decreased growth factor levels, which is contrary to the literature data. CONCLUSION Fat grafting has an immunohistochemical effect on the growth factor levels that are related to angiogenesis after urethral repair. It is difficult to make a firm conclusion about the role of fat grafting on urethral healing. Therefore, future studies are needed to see if FG can be used as an alternative to other procedures in order to avoid complications.