İsmail Kuran

Comparison between Sensitive and Nonsensitive Free Flaps in Reconstruction of the Heel and Plantar Area

In this study, 12 cases of reconstruction of the heel and plantar area since 1982 are reviewed. Six nonsensate muscle free flaps and six sensate fasciocutaneous flaps were used, respectively. Categories assessed were the time interval for return to daily living activities, sensation to light touch, pinprick, Semmes-Weinstein monofilament test of the reconstructed area for sensory evaluation; and results of pedograms (maximal pressure, pressure distribution, and total contact area of the plantar surface). Follow-up periods were between 2 and 14 years, with an average of 6 years. Better sensory results and early return to daily living activities were observed in the sensate flap group, but the defects were smaller in this group. Despite the slightly longer time to return to daily living activities and worse sensory results, long-term follow-up showed that patients with nonsensate flaps had no difficulty in performing living activities if they continued to be careful and to use some kind of protective shoes. The results of the pedogram analyses were similar between the two groups with regard to total contact area of the reconstructed foot in relation to the healthy foot. Pressure values of the reconstructed areas in sensate flaps were found to be close to pressure values in the same weight areas of the normal foot. The differences between pressure values of the sensate and nonsensate flaps were statistically significant (p < 0.001). Therefore, in reconstruction of the weight-bearing surface of the foot, each case should be evaluated individually. The reconstructive method should be chosen according to the location and soft-tissue requirements of the defect.

Comparison of four different types of osteotomes for lateral osteotomy: A cadaver study

In this study, four different types of osteotomes were compared in lateral osteotomy of cosmetic rhinoplasty. For this purpose, 32 halves of 16 cadavers were used. Fracture line and mucosal injuries were evaluated. Statistical analyses were made to find out if there is any relation between the type of osteotomes and the extent of injury. At the same time bone thickness was measured on the osteotomy line. Wide osteotomes have shown more mucosal injuries which is statistically significant. Bone thickness does not exceed 3 mm at any point on the osteotomy lines.

A New Simple Method Used to Prepare Fat for Injection

Various clinical and experimental studies on harvesting techniques, donor sites, preparation, and preservation of fat for injection imply that there is no universal agreement on an ideal methodology. Unpredictable and irregular resorption of fat leads to uncertainty about volume maintenance of the transplanted fat necessitating repeat procedures. In this report, the authors present their 5-year clinical experience with facial fat grafting by isolated and combined procedures using a simple method that they developed for fat preparation. This technique includes fat harvesting with syringe aspiration and filtration of the fat aspirate instead of centrifugation. The idea for filtration was inspired by a yogurt concentration method used in Anatolia. The authors also aimed to increase fat survival by using multiple fat injections of minimal amounts into different levels.

Nasal Reconstruction Based on Subunit Principle Combined With Turn-Over Island Nasal Skin Flap for Nasal Lining Restoration

The reconstructive plan of full-thickness nasal defects should include recreation of internal nasal lining, skeletal and cartilaginous support and external cover. We performed nasal reconstruction combined with turn-over island nasal skin flap for nasal lining reconstruction in 12 patients who underwent full-thickness resection of nasal area because of skin cancer. The flap filled the nasal lining defect of the alar area and provided a good support for skeletal reconstruction. The external skin coverage, which was enlarged according to the subunit principle, was restored by the forehead skin flap at the same operation. Enlarging the nasal defect according to the subunit principle and using the residual skin as a turn-over skin island flap for nasal lining, combined with forehead skin flap for external coverage, provides an excellent nasal reconstruction in a single operation.

The Lateral Crural Rein Flap: A Novel Technique for Management of Tip Rotation in Primary Rhinoplasty

BACKGROUND An important consideration in rhinoplasty is maintenance of the applied tip rotation. Different techniques have been proposed to accomplish this. Loss of rotation after surgery not only results in a derotated tip but also can create a supratip deformity. OBJECTIVES As a supplement to dorsal reconstruction, the authors introduced and applied the lateral crural rein flap technique, whereby cartilage flaps are created from the cephalic portion of the lateral crura to control and stabilize tip rotation. METHODS Eleven patients underwent primary open-approach rhinoplasty that included the lateral crural rein technique; the mean follow-up time was 18 months. Excess cephalic portions of the lateral crura were prepared as medial crura-based cartilaginous flaps and were incorporated into the nasal dorsum (similar to spreader grafts) and stabilized to achieve the desired tip rotation. RESULTS The lateral crural rein flap technique provided stability to the nasal tip while minimizing derotation in the postoperative period. Long-term follow-up revealed maintenance of the nasal tip rotation and symmetric dorsal aesthetic lines. CONCLUSIONS The lateral crural rein flap technique is effective for controlling nasal tip rotation while reducing lateral crural cephalic excess. Longevity of the applied tip rotation is reinforced by secure attachment of the lower nasal cartilage complex to the midvault structures. LEVEL OF EVIDENCE 4.

Comparison of accuracy of three-dimensional spiral computed tomography, standard radiography, and direct measurements in evaluating facial fracture healing in a rat model.

Complex maxillofacial fractures demand a detailed understanding of the three-dimensional (3D) pattern of injury. Evaluation of the outcome of the facial fracture repair additionally requires optimal demonstration of fracture gap, bony union, fibrous callus or incorporation of fracture ends, presence of incomplete fusion, or pseudoarthrosis. Although 3D computed tomography (CT) is reliably used for the diagnosis of complex facial fractures, its value in facial fracture healing is unknown. An experimental study was conducted to determine the accuracy of 3D spiral CT scans in evaluating facial fracture healing during the early and late postoperative periods. In 10 adult Wistar Albino rats, a standardized bone defect (3 mm) was created within the mid portion of each zygomatic arch (n = 20). At 10 and 20 weeks postfracture, gap distance displayed by 3D CT and plane radiography (posteroanterior) were measured. At 20 weeks postfracture, intraoperative measurement was also performed. A comparison between 3D CT, radiography, and intraoperative findings was performed. At 10 weeks postfracture, the fracture sites displayed larger bone defects in imaging with 3D CT than with plane radiography. The difference between groups was statistically significant (P < 0.05). The mean defect size imaged by 3D CT was 0.91 ± 0.82 mm (standard deviation) and by plane radiography was 0.42 ± 0.16 mm. At 20 weeks postfracture, the mean defect size imaged by 3D CT was 0.56 ± 0.64 mm, and by plane radiography was 0.38 ± 0.22 mm. The difference between groups was not statistically significant (P > 0.05). The defect size imaged by both plane radiography and 3D CT was significantly less than the measurement obtained from the intraoperative assessment (P < 0.05). It was concluded that 3D CT has limited benefit in the detection of newly formed bone at week 10 and in the detection of fibrous callus, which can eventually give rise to the bony tissue. Plane radiography is more valid during the early postoperative period (week 10), because it can detect the fibrous callus and newly formed bone more precisely. Gap distance between fracture ends could be determined by 3D CT accurately at week 20, although there was a tendency, which was not statistically significant, to overestimate the amount of bone defect measured by 3D CT when compared with that of plane radiography.

Vertical Reduction Mammaplasty: Preventing Skin Redundancy at the Vertical Scar in Women With Large Breasts or Poor Skin Elasticity

The authors describe a vertical reduction mammaplasty technique for avoiding skin excess at the vertical scar. Conical projection of the breast is achieved by cranial to caudal gland-shaping sutures. Excision of redundant skin is performed in a triangular pattern, creating bilateral dog ears. Resection of these dog ears results in a short, symmetrical horizontal scar located at the new submammary line.

The sandwiched lateral crural reinforcement graft: a novel technique for lateral crus reinforcement in rhinoplasty.

BACKGROUND Misshapen or weak lateral crura can cause an inward collapse of the lateral crus observed on deep inspiration. The lateral crural strut graft is a popular technique for reinforcing lateral crura. Failure to stabilize the graft properly can, however, result in graft displacement postoperatively and an accompanying aesthetic deformity. OBJECTIVES The authors discuss lateral crus reinforcement with the sandwiched lateral crural reinforcement (SLCR) graft. METHODS An SLCR graft was placed in 30 nonconsecutive primary open-approach rhinoplasty procedures by the senior author (İ.K.) between February 2010 and May 2012. Cephalic excess of the lateral crura was incised and placed under the lateral crura; the lateral crural strut grafts were placed between the 2 cartilages, and the cephalic edges of both the superior and inferior lateral crura segments were sutured together. RESULTS Of the 30 patients, there were 5 men and 25 women ranging in age from 22 to 45 years (median, 35 years). Half (50%) of the patients received the SLCR graft for external valve collapse; in 30% of the patients, it was placed to support the lateral crura after correcting cephalic malpositioning; and 20% had an SLCR graft placed for lateral crural reinforcement after deformity secondary to dome-shaping sutures. No graft displacement or tip disfigurement was observed in the follow-up period (mean, 24 months). CONCLUSIONS The SLCR graft technique represents a powerful tool for reinforcing lateral crura without discarding the cephalic portion of the cartilage, thus securing a stable graft pocket while minimizing any postoperative structural dislocation. LEVEL OF EVIDENCE 4.

Hair Removal with the Long-Pulse Alexandrite Laser

BACKGROUND Although laser depilation has been performed for removal or reduction of unwanted and dark-colored hair in recent years, techniques including the appropriate approaches for different skin types and body areas have not yet been optimized. OBJECTIVE We review the principles of laser hair removal and report a retrospective study of 322 patients who received long-pulse alexandrite laser hair removal for 3 or more sessions between January 2000 and December 2002. METHODS Prior to treatment, patients were evaluated by a physician and informed of the mechanism, efficacy, and possible side effects of treatment. Patients were classified by skin type according to the Fitzpatrick classification. Those patients with systemic disease, a history of sun sensitivity, or who had used drugs known to cause photosensitivity were excluded from laser treatment. All treatments were performed with a long-pulse alexandrite laser with a constant spot size (18 mm) and 3-ms pulse width that applied energy of 755 nm. Sessions were repeated at different intervals depending on the body parts to be treated. RESULTS The overall hair reduction rate for all patients, independent of skin type, was estimated as 80.8%. There were 2 cases of hypopigmentation and 8 cases of hyperpigmentation post-treatment. No other complications were reported. CONCLUSIONS Treatment with the long-pulse alexandrite laser can meet the expectations of patients who desire permanent hair removal. Careful examination of patients prior to therapy, as well as thorough patient education, are essential to patient compliance and success with this technique.

Posttraumatic compensatory lipodystrophy

highest incidence is in the first 6 weeks post partum with Staphylococcus aureus the most common isolate. Our first two patients had the typical patient’s profile for mastitis and abscess. Though the first patient’s mastitis responded and promptly settled with an appropriate antibiotic, she was left with a residual seroma, a complication previously unreported. In our second patient, it is probable that she developed a breast abscess and subsequent implant extrusion due to the nature of MRSA, a multi-drug resistant organism. Furthermore, the second patient developed Baker III capsular contractures in the opposite breast and we believe these maybe consequent upon the preceding events. In the third patient, her history of implant rotation was consistent with our clinical finding of an ‘upside-down’, rotated implant which was confirmed by MRI. The larger size of the affected breast during pregnancy is suggestive of pregnancy-related seroma formation as a cause of the implant rotation. We hypothesise that as a result of spontaneous resolution of the seroma after pregnancy, the implant did not de-rotate. These three pregnancy-associated complications of the augmented breast are previously unreported. Further studies on pregnancy following breast augmentation will shed more light on the true incidence. We hope that this article will raise the awareness of doctors and, ultimately, patients on the need for prompt diagnosis and treatment should symptoms of mastitis develop in the presence of breast implants.