Mümtaz Güler

Nerve regeneration through side-to-side neurorrhaphy sites in a rat model : A new concept in peripheral nerve surgery

Despite great improvement and refinements in nerve repair techniques, there were still problems in repair of peripheral nerve injuries for which proximal stumps were not available. In these circumstances for which classic end-to-end neurorrhaphy was impossible, new treatment modalities, benefiting by an adjacent healthy nerve, have been under investigation to overcome this problem. Therefore, end-to-side nerve repair with its modifications came to view and axonal passages through this site were shown. Moreover, the results were unsatisfactory or necessitating sacrifice of another healthy nerve. Three groups, containing 10 rats each, were included in the study. First was the control group, with end-to-end repair of the peroneal nerve. Second was the end-to-side repair group, in which the distal stump of the peroneal nerve trunk was anastomosed to the lateral side of the tibial nerve. The third was the side-to-side repair group. In this technique, 1-mm diameter epineural windows, both from peroneal and tibial nerve trunks facing each other, were removed and side-to-side neurorrhaphy was performed. After 3 weeks, as the second step, the peroneal nerve was sectioned proximally. At 2, 4, 8, 12, 20, and 28 weeks, functional assessment of nerve regeneration was performed by using walking track analysis. The number of myelinated fibers and fiber diameters were measured and an electron microscopic evaluation was carried out. Statistically, both in morphometric and gait analysis, the differences in values between the groups were significant in favor of the control group, followed by the side-to-side group. The study showed that axonal passage was possible with side-to-side technique and the functional results were satisfactory and superior to the end-to-side technique. Continuous supply of neurotrophic factors from their target cells was the probable cause of superior functional return in side-to-side repair, because both joining nerves were intact and healthy during the anastomosis procedure and after 3 weeks. It was concluded that this technique could be indicated in salvage of nerves in cases for which any intermediate segments would be removed, as in tumor ablation surgery, harvesting of nerve grafts, or both.

Reconstruction of Saddle Nose Deformities Using Porous Polyethylene Implant

Abstract. Various materials have been employed for nasal contour restoration. We used porous polyethylene implants in reconstruction of saddle nose deformity in 36 cases. Only one complication occurred in the 8–18 months follow-up period. No implant was removed. Both cosmetic and functional results were accepted as pleasing by the patients.

Treatment of burn scar depigmentation by carbon dioxide laser-assisted dermabrasion and thin skin grafting

Permanent depigmentation occasionally develops after deep partial-thickness and full-thickness burn injuries, which heal by secondary intention. This problem can be solved by dermabrasion and thin split-thickness skin grafting. However, mechanical dermabrasion is a bloody procedure that risks exposing medical professionals to infectious diseases transmitted by blood products, and it is difficult to assess the extent of tissue ablation. In this study, dermabrasion of depigmented burn scar area was performed by using flash-scanned carbon dioxide laser treatment, followed by thin split-thickness skin grafting. This method was applied to 13 patients on whom burn scar depigmentation sites were located as follows: two in the facial area, four on the trunk, and seven on the extremities. Skin graft take was excellent in all patients except for one. The follow-up period for these patients ranged from 1 to 12 months, with an average of 8 months. Repigmentation appeared soon after grafting, and no depigmentation occurred again in the treated areas. In conclusion, depigmented burn scar areas can be dermabraded in a short time; depth of tissue ablation can be well controlled; and a bloodless and smooth raw surface can be created by using a flash-scanned carbon dioxide laser. These raw surfaces sustain thin skin grafts well. (Plast. Reconstr. Surg. 105: 1973, 2000.)

Burn scar carcinoma with longer lag period arising in previously grafted area

A case of Marjolins ulcer that arose in previously grafted area of right ankle 55 years after initial burn injury was managed by below knee amputation and right inguinal lymph node dissection. The characteristics of this malignancy were reviewed, and rarely seen features particular to this case, which are a longer lag period and rapid growth in a previously grafted area, were discussed.

Reconstruction of foot defects due to mine explosion using muscle flaps

Landmine explosions bring a formidable challenge to both patients and reconstructive surgeons. Free tissue transfer is the only method of repairing such extensive soft tissue defects of the foot after serial debridements. Sixty‐five consecutive free muscle flap transfers were performed in 54 patients who had foot defects involving soft tissue and bone due to mine explosions. Although posttraumatic vessel disease had complicated most of the cases, overall flap survival rate was 83%. Each patient was ambulatory. Ulceration in long‐term period was seen in only one patient. Eighty‐five percent of patients with successful bone reconstruction and 41.6% of patients without adequate bone replacement demonstrated normal weightbearing in footprints and gait analysis. Free muscle flaps with split thickness skin graft and bone replacement are recommended for the reconstruction of such devastating wounds.

Salvage of foot amputation stumps of Chopart level by free medial plantar flap.

&NA; Blast energy‐induced traumas usually result in some type of amputations of lower extremities. It is very hard to determine the amputation level of the feet of these cases at first, and secondary amputation stump revisions by bone shortening are often necessary. Among partial foot amputation levels, Chopart level is the most critical. Four male patients (20 to 24 years old) with modified Chopart amputation due to mine explosion injury have had skingrafted amputation stumps where troublesome, recurrent unstable wounds had developed. These amputation stumps were electively reconstructed with neurosensorial free medial plantar flaps from unaffected feet without any bone shortening. All the transferred flaps survived and adapted to stumps well, and patients were ambulated at the second month by wearing on the original prosthesis after minimal adjustments. At the follow‐up period (6 months to 2 years), no skin breakdown of the stumps was evident. Monofilament (Semmes‐Weinstein) tests revealed diminished light touch in two patients and diminished protective sensation in another two patients at the sixth month. Temporary donor foot pain, which existed by walking for 3 months, may be due partly to absence of plantar fascia supporting the plantar arc. We suggest that amputation level of Chopart is the most critical of partial foot amputations in young patients and should be reconstructed with flaps if there is not sufficient soft‐tissue coverage of amputation stump; free neurosensorial medial plantar flap would be the primary choice with its advantages.

Subcutaneous Metallic Mercury Injection: Early, Massive Excision

The case of a patient who injected 10 cc of metallic mercury subcutaneously into his left forearm through multiple punctures in an attempt at suicide is presented. Diagnosis was made by plain radiography of his left forearm, which exhibited redness, edema, and tenderness on the third day postinjection. Early excision of all affected subcutaneous tissues including metallic mercury deposits was performed on the fifth day postinjection. Blood and urine mercury levels that were initially found in high levels decreased dramatically to normal ranges after the excision and remained unchanged at the follow-up period of 6 months. No renal or hepatic functional impairment was encountered. The patient was free of toxic symptoms and mercury embolism. The local, aseptic lytic property of metallic mercury, which could cause severe damage to vital structures, was observed perioperatively. Early diagnosis and early, massive excision of mercury deposits in affected tissues is the important treatment modality in these rare cases.

Prolonged intermittent hydrotherapy and early tangential excision in the treatment of an extensive strong alkali burn

It is well known that the first step in the treatment of cutaneous strong alkali burn is very early and persistent washing of the site of injury with large volumes of water. However, ideal duration and the technique of hydrotherapy has not yet been established. Besides hydrotherapy, tangential excision of the injured skin might prevent further tissue damage if it is performed early enough. We report the treatment of a 36-year-old male who sustained 53% body surface area (BSA) cutaneous burn due to caustic soda (NaOH). Prolonged intermittent hydrotherapy, early tangential excision and autografting of the injured skin are the keys for the proper management of extensive strong alkali burn.

Replantation of an avulsive amputation of a foot after recovering the foot from the sea.

A foot avulsion case, with the dismembered body part submerged in sea water for 1 hour, is presented. This report is unique in that it is the first to document the reattachment of a body part that had been submerged in sea water. It was not known how salt-water exposure would affect wound management. Differences in osmolarity and bacterial flora between the sea water and foot tissues have not caused any problems, and the patient has not suffered any vascular or infectious complications after replantation. Neurotization of the plantar surface by the tibial nerve, which was stripped off during amputation and replaced in its original traces, was the most critical part of convalescence. After management of such an interesting case, we conclude that exposure to sea water of the dismembered part should not be a contraindication for replantation surgery.

Three‐dimensional reconstruction of types iv and v midfacial defects by free rectus abdominis myocutaneous (RAM) flap

Extensive midfacial defects after ablative surgery constitutes a challenging problem for reconstructive surgeons. Particularly for types IV and V midfacial defects, provision of missing bony support and obliteration of the maxillary cavity defects require microsurgical free tissue transfers. In the last three years, four patients have undergone total maxillectomy for midfacial tumours and the postmaxillectomy defects were three‐dimensionally repaired with free rectus abdominis muscle flap and skin graft or myocutaneous flaps. Obliteration of maxillary cavity defects and orbital support were achieved with this type of free flap. The least follow‐up period of the patients is one year and slight ectropion, later corrected, was seen in two patients. In this study, the free rectus abdominis myocutaneous (RAM) flap, with its long vascular pedicle and availability of various skin paddle designs and muscle bulk, is presented in treatment of extensive midfacial defects. In spite of initial overcorrection of contour, the denervated rectus abdominis muscle gradually atrophies, resulting in loss of contour. The muscle bulk fills the cavity defect, but, in order to achieve good facial contour, it is necessary to support the bony skeleton with some material.