Levent Yoleri

The cranially based contralateral nasolabial flap for reconstruction of paranasal and periorbital surgical defects

The importance of the paranasal and periorbital regions on the aesthetics of the face presents a variety of reconstructive challenges for surgical and traumatic defects of those regions. We used the cranially based nasolabial flap in patients with full-thickness soft-tissue defects of the paranasal and periorbital regions harvested from the contralateral side of the present defect. We present our experience in 25 patients of geriatric population (13 females and 12 males with a mean age of 76) with complex soft-tissue defects in the paranasal and periorbital regions whose defects were reconstructed with contralateral nasolabial skin flaps. Sizes of the defects changed between 2 × 3 cm and 6 × 7 cm. The flap sizes varied from a width of 2 to 5 cm (average 3 cm) and a length of 7 to 11 cm (average 8 cm). Primary closure of the donor sites of the flaps was possible in 24 of the patients in this series. Twenty-one flaps of this series (84%) healed without any necrosis and completely survived. The contralateral nasolabial flap is a very convenient, safe and reliable flap that can be used in medium to large paranasal and periorbital defects. Optimal aesthetic results for a variety of central facial defects could be obtained with this flap, especially when the ipsilateral nasolabial flap cannot be used due to various reasons.

Tension adjusted multivectorial static suspension with plantaris tendon in facial paralysis.

AbstractFacial paralysis in the midface causes loss of cheek tonus, asymmetry at rest, and inability to smile. Static suspension is generally performed in patients who cannot tolerate time-consuming dynamic reanimation. Current methods for static slings are overly simplistic. A sling, which is generally fascia lata or palmaris tendon, is placed between the modiolus and the zygomatic arch or the temporalis fascia, with further extension to the midline of the upper end lower lips in 1 vector. Recently, sutures are placed in a multivectorial approach, but suture failure via breakage is the main problem. In this study, the long, thin, and powerful plantaris tendon was used and divided into 3 slips. Placement of these slips and their tension adjustment were revised to provide strong and long-lasting upper lip and the modiolus pull, along with creation of a well-defined nasolabial fold, and to create sufficient cheek tonus. The first slip was positioned at 35 to 45 degrees to the horizontal plane between the modiolus and the upper preauricular area, second slip at 55 to 60 degrees between the upper lip and the deep temporal fascia, and the third slip at 0 to 10 degrees between the lower lip and lower preauricular area with gradually decreasing tension from above to below in 9 patients. Upper 2 slings were also sutured to the dermis of the nasolabial fold to define it optimally. Results were assessed both objectively and subjectively. Symmetry at rest, sufficient cheek tightness to prevent drooling, and a well-defined fold were obtained.

Lateral thoracic artery perforator-based flap: a new experimental model.

BACKGROUND The aim of this study was to describe a new experimental perforator-based flap in rats, supplied by lateral thoracic artery perforator. METHODS Through out the study, two control and two experimental groups were created consisting of six rats in each group. In the first control group (group 1), mid-axillary line and the fourth intercostal space intersection were used as the center of the flap. A 3 × 2 cm flap was designed and elevated above the cutaneous maximus muscle by transecting all connections with the muscle. In the second control group (group 2), the flap was extended caudally, and 3 × 6 cm flap was designed. Then, the flap was elevated in the same manner as it was described for group 1. In the first experimental group (group 3) 3 × 2 cm flap and in the second experimental group (group 4) 3 × 6 cm flap were designed like control groups. The flaps were islanded on a single musculocutan perforator arising from lateral thoracic artery. The surviving skin paddle areas were calculated on postoperative day 7. RESULTS The flap viability was calculated 0% for control groups (groups 1 and 2), 100% for the first experimental group (group 3), between 33.3% and 37.7% for the second experimental group (group 4; mean ± standard deviation, 34.76% ± 1.92%). CONCLUSIONS This new lateral thoracic artery perforator-based flap has a constant anatomy and reliable survival pattern. Also, easy harvesting and the possibility of designing two flaps per animal make this new flap an appealing model for pathophysiological or pharmacologic researches.

Nonsyndromic giant basal cell carcinoma with follicular differentiation and multifocal localized basal cell carcinoma.

Basal cell carcinoma is the most common malignant tumor of the skin. The most important feature is its very slow growth rate. It takes many years to reach gigantic dimensions. Various syndromes have been defined in which basal cell carcinoma exists in multiple localizations in a single patient. A case of basal cell carcinoma with multiple localizations and gigantic dimensions which is not classified as a syndrome is described in this case report.

Malignant tumor of outer root sheath epithelium, trichilemmal carcinoma. Clinical presentations, treatments and outcomes

Objectives: To emphasize different clinical features of tumor that can be misdiagnosed clinically. Methods: A total of 8 cases operated between September 2009 and 2016 at the Celal Bayar University, Faculty of Medicine were included in the study. Patients’ clinicopathological features, type of surgery and follow up information were evaluated. Results: Six patients were male. The average age was 75.50. The lesions were located on the head and neck, and chest wall. Six patients had a history of the rapid growth of lesion. There was no metastasis at the time of diagnosis. None of the patients needed adjuvant therapy. Mean follow up time was 19.37 months. None of the patients developed recurrence or metastasis. Conclusion: This tumor resembles basal or squamous cell carcinoma. The histopathological evaluation may lead to misdiagnosis. Regional or distant metastasis is very rare. There is no consensus about adjuvant therapy. Screening for metastasis and close follow up are mandatory.

Idiopathic Scrotal Elephantiasis

Lymphedema is a condition caused by extra-cellular fluids accumulating in subcutaneous compartments as a result of lymphatic obstruction. Etiologically it can be classified as primary (congenital) and secondary (acquired). Primary lymphedema can be seen to be associated with congenital lymphatic hypoplasia, as a component of a genetic syndrome such as Milroy’s disease or Meigs syndrome.1 Secondary lymphedema is usually seen following an obstruction. The most common cause of secondary lymphedema in the world is filariasis, but the number of lymphedema cases secondary to radiotherapy and lymph node dissections is also rapidly increasing. In males, genital lymphedema can be isolated to the penis or the scrotum, or affects both. This condition can be either idiopathic, or occur secondarily to a surgery, trauma, radiation, tumor or infection in lymph nodes where the major lymphatics of the genital region are drained.2 Once the flow of lymphatic fluid is disrupted, a pathophysiologic process that disrupts cellular migration in the immune system is initiated with the fluid accumulating in the distal tissues containing macromolecules and proteins. This results in cellular expansion, loss of elasticity, and a tendency to infection. Pervasive fibrosis develops in the region. Thus, recurrent erysipelas, lymphatic cysts, and lymphuria, giant mass decubitus ulcers, and hygienic problems are frequently encountered in enlarged genital organs. Additionally, micturition difficulty and sexual dysfunction are fundamental issues impacting a reduced quality of life.1 In this study we present a very rarely seen idiopathic case of isolated massive scrotal lymphedema. This case is of significance in that it demonstrates that an isolated lymphedema can grow into massive sizes and lead to partial systemic disorders even if the patient has not undergone surgery.

True Retaining Ligaments of Face as Surgical Landmarks

La adherencia de los tejidos que recubren a las estructuras subyacentes en la cara se mantiene por los ligamentos de retencion. Los ligamentos de retencion verdaderos llamados ligamentos orbitales, cigomatico y mandibular son una serie de bandas fibrosas que se extienden desde el periostio a la dermis. El efecto de la inmovilizacion de los verdaderos ligamentos de retencion debe ser liberado para lograr un movimiento satisfactorio de la piel del rostro y del SMAS durante los procedimientos de estiramiento facial. El objetivo fue definir la ubicacion de los verdaderos ligamentos de retencion de la cara para discutir su utilidad como puntos de referencia quirurgicos. El estudio se realizo sobre diez hemi-caras de cadaveres, fijadas con formalina. Las disecciones se asemejaron a los procedimientos de estiramiento facial, se aplicaron y determinaron los ligamentos. Se midieron las distancias de los ligamentos al canto lateral, trago, comisura y a las lineas de trago a canto lateral y comisura. Las correlaciones fueron analizadas estadisticamente. Las distancias de los ligamentos cigomatico y mandibular desde el trago fueron 66,50±10,78 mm y 114,80±9,76 mm, respectivamente. Las distancias del ligamento cigomatico a la comisura y la linea de comisura al trago fueron 56,30±8,94 mm y 28,40±5,19 mm, respectivamente. Las distancias de los ligamentos cigomatico y mandibular desde el trago estaban correlacionadas de forma importante con una relacion de 3/5 y habia una fuerte correlacion entre las distancias del ligamento cigomatico desde la linea de comisura y el trago - con una relacion de 2. Los resultados de este estudio han dilucidado la posibilidad de la utilizacion de los verdaderos ligamentos de retencion como puntos de referencia quirurgicos para la cirugia facial.

Asymmetry, Handedness and Auricle Morphometry

El objetivo de este estudio fue determinar diversas mediciones morfometricas de la oreja, para investigar la asimetria y su relacion con el uso de las manos en ambos sexos. Se realizaron mediciones morfometricas de los pabellones auriculares y las manos de 400 estudiantes universitarios (200 hombres y 299 mujeres). Todas las medidas de las orejas fueron mayores en los hombres y todas las diferencias, excepto las correspondientes al ancho del lobulo auricular, fueron estadisticamente significativas. Todas las mediciones de los pabellones auriculares izquierdos y derechos presentaron diferencias estadisticamente significativas en ambos sexos, excepto en el caso de la longitud del lobulo auricular en los hombres, y la distancia desde el punto mas alto de la oreja a la parte inferior de la incisura intertragica en el lobulo auricular de las mujeres. La longitud de la oreja y la distancia desde el punto mas alto de la misma a la parte inferior de la escotadura intertragica tenian valores mas altos en el lado izquierdo y todas las demas mediciones fueron mas elevadas en el lado derecho. No hubo diferencia significativa entre las mediciones de las orejas correspondientes a los sujetos diestros y zurdos. Todas las mediciones fueron superiores en el lado derecho, excepto la longitud del pabellon auricular y la distancia desde el punto mas alto de la oreja a la parte inferior de la incisura intertragica en sujetos diestros y sujetos zurdos, y todas las diferencias, excepto la longitud del lobulo auricular, fueron significativamente diferentes en los sujetos diestros como en la poblacion total, pero en sujetos zurdos la diferencia de la anchura de la oreja no fue significativa. Se encontro una aparente asimetria en las orejas derecha e izquierda de los sujetos del presente estudio que debe tenerse en consideracion en las cirugias plasticas del oido externo, para el diseno de los dispositivos de audicion y para su aplicacion en estudios forenses de las huellas de la oreja.

Use of cytarabine and idarubicin in a newly diagnosed AML patient with a severe wound.

Acute myeloid leukemia (AML) is malignant tumor of haemopoietic precursor cells of non-lymphoid lineage. AML can atypically present with non-spesific cutaneous lesions or wounds. There are rare acute leukemia cases which present with genital ulcerations or pyoderma gangrenosum in the literature. The effect of acute leukemia on wound healing is not known, but it is thought that cytopenias and chemotherapy can impair wound healing in patients with leukemia. The effects of chemotherapeutic agents on wound healing are arguable. Here we present wound care strategies and simultaneously applied chemotherapy in an AML patient.

Remodeling of a nontreated displaced parasymphyseal fracture of a child.

There have been considerable advances in the management of craniomaxillofacial injuries in children. Conservative approaches such as close observation, a liquid-to-soft diet, and analgesics can be used for the management of mandibular fractures without displacement and malocclusion. However, displaced fractures need to be an anatomic reduction and immobilization. The basic principle of displaced mandibular fractures in both children and adults is the stabilization of fracture fragments forming the pretraumatic contour and occlusion state until osteosynthesis occurs. The major differences of pediatric fractures from adults are the flexibility of bones and very rapid healing pattern. Therefore, reduction in pediatric age group must be accomplished earlier. This case was an 11-year-old boy presented with a severely displaced parasymphyseal mandibular fracture resulting from a fall. He was given a soft diet and analgesic, given anti-inflammatory treatment of edema, and scheduled for operation. Subsequently, it was surprisingly observed that there was a significant improvement in the fracture line on the 12th posttraumatic day. The comparison of maxillofacial computed tomographic scans of the first and 12th posttraumatic days revealed a noteworthy remodeling and a remarkable approximation of the fracture lines. It can be concluded that bone remodelization in the pediatric age groups is perfect and very rapid, even in severely displaced fractures.