Murat Topalan

Supermicrosurgical lymphaticovenular anastomosis and lymphaticovenous implantation for treatment of unilateral lower extremity lymphedema

Recent supermicrosurgical techniques have developed the possibility for vascular anastomosis of smaller vessels and it is now safe and sound to perform precise anastomoses between lymphatics and venules. Reported here is the 2 years experience on supermicrosurgical lymphaticovenular anastomosis and/or lymphaticovenous implantation combined with a nonoperative physical therapy for treatment of lower extremity lymphedema. Microlymphatic surgery was performed in 42 patients with unilateral lower extremity lymphedema. Thirty patients were women and 12 were men with a mean age of 34. Lymphaticovenular anastomoses were performed in 37 patients with an average of 2.5 anastomoses per patient, and lymphaticovenous implantations were made in 36 patients with an average of 2.4 implantations per patient. The lymphatics that were larger than 0.3 mm were anastomosed to venules with supermicrosurgical technique. Lymphaticovenous implantation technique was used for thinner lymphatics in a particular incision. Postoperatively, 18 patients used continuous compressive garments, 9 patients used garments but discontinued after 6 months, and no compression was used in 9 patients. The results of surgery were assessed both clinically with volume measurements and by lymphoscintigraphy and were classified as good, moderate, or ineffective. The mean decrease in the volume of the edema was 59.3% at an average follow‐up of 11.8 months. Six outcomes were classified as ineffective, eight outcomes as moderate, and 28 outcomes as good. Supermicrosurgical lymphaticovenular anastomosis and/or lymphaticovenous implantation seems to be highly beneficial, especially in the early stages of peripheral lymphedema and may be offered as the treatment of choice in selected patients.

Actinomycosis of the frontal and parotid regions.

Cervicofacial actinomycosis still occurs infrequently and should be included in the differential diagnosis of neoplasms, and chronic suppurative and granulomatous lesions of the head and neck region. The authors present two cases of actinomycosis. Patient 1 was a 32-year-old man who was first seen with a firm, suppurative mass at his left frontal region. Patient 2 was a 36-year-old woman with an indurated mass at her left parotid area. Both patients were diagnosed histopathologically with cervicofacial actinomycosis, but each patient had a different clinical course and different response to antimicrobial and surgical treatments.

Comparison of Primary and Secondary Lower-Extremity Lymphedema Treated with Supermicrosurgical Lymphaticovenous Anastomosis and Lymphaticovenous Implantation

Although some authors previously stated that microlymphatic surgery does not have application to primary lymphedema, opposite views are reported based on the observations that the lymphatics were not hypoplastic in majority of these patients and microlymphatic surgery yielded significant improvement. The aim of this study was to compare the intraoperative findings and outcomes of primary and secondary lower-extremity lymphedema cases treated with lymphaticovenous shunts. Between December 2006 and April 2009, microlymphatic surgery was performed in 80 lower extremities with primary and 21 with secondary lymphedema. These two groups of extremities are compared according to the morphology of the lymphatic vessels and possibility of precise anastomoses, their response to the treatment, and final outcomes based on volumetric measurements during the follow-up period. The morphology of the lymphatics in secondary lymphedema was more consistent, and at least one collector larger than 0.3 mm was available for anastomosis in 20 of 21 extremities. In the primary lymphedema group, the lymphatics were smaller than 0.3 mm in 13 of 80 extremities. It was, therefore, possible to perform supermicrosurgical lymphaticovenous anastomosis in 84% of extremities with primary lymphedema and 95% of extremities with secondary lymphedema. Reduction of the edema occurred earlier in the secondary lymphedema group, but the mean reduction in the edema volume was comparable between the two groups. Microlymphatic surgery, although more effective and offered as the treatment of choice for secondary lymphedema, would also be a valuable and relevant treatment of primary lymphedema.

Hemifacial resurfacing with prefabricated induced expanded supraclavicular skin flap.

BACKGROUND Severe facial burn sequelae present a great challenge and maximally test the principles of reconstructive surgery. Three of these basic principles--free tissue transfer, flap prefabrication, and tissue expansion--are combined to achieve superior reconstructive outcomes. This approach evolved into the prefabricated induced expanded flap, which refers to the staged transfer of expanded supraclavicular skin with an antebrachial fascial free flap used as the carrier. METHODS In the first surgical stage, the radial artery and corresponding vein in antebrachial fascia were transferred to a subcutaneous pocket in the supraclavicular fossa over a large skin expander, with anastomoses to the neck vessels. During the second stage, after adequate expansion lasting 2 to 3 months, the total scarred hemiface was excised, and the prefabricated induced expanded flap was dissected and then transferred as an island to cover the skin defect. RESULTS Twenty-six patients with severe hemifacial burn sequelae and three more with other large hemifacial lesions underwent successful facial resurfacing with the described technique in the last 7 years. Twenty patients were male and nine were female, with a mean age of 23. Mean follow-up was 3.4 years. All of the flaps survived after transfer, and no major complication was observed. CONCLUSIONS The supraclavicular prefabricated induced expanded flap can provide ample amounts of vascularized, thin, and desirable skin with perfect color match for resurfacing major facial defects. The aesthetic and functional results were encouraging and progressively improved during follow-up.

The results of surgical repair of sciatic nerve injuries

OBJECTIVES The aim of this study was to evaluate surgical treatment and follow-up results of patients who presented to our department with sciatic nerve injuries. METHODS The study included 13 patients (12 males, 1 female; mean age 23 years; range 11 to 35 years) who underwent surgical treatment for sciatic nerve injuries. The etiologies of sciatic nerve injuries were penetrating trauma in five patients, firearm injuries in four patients, and motor vehicle accidents in four patients. Injuries involved the knee level in five patients, and above-the-knee level in eight patients. Peroneal nerve involvement was seen in all the patients, and the tibial nerve was involved in 11 patients. Primary repair was performed in six patients, neurolysis in three patients, and nerve grafting in three patients. One patient underwent neurolysis for the peroneal portion, and nerve grafting for the tibial portion. Muscle strength and reflex changes were recorded at every stage of the treatment. Muscle strength was assessed according to the British Medical Research Council scale. The Semmes-Weinstein monofilament test was used for sensory evaluation. The mean follow-up period was 4 years (range 1 to 6 years). RESULTS In 11 patients with tibial nerve injuries, the soleus/gastrocnemius strength was measured as follows: M1 in one patient, M3 in four patients, M4 in four patients, and M5 in two patients. Plantar sensation was absent in four patients, while seven patients had at least adequate protective sensation. In 13 patients with a peroneal nerve injury, the strength of the anterior tibial muscle was measured as follows: M0 in three patients, M2 in three patients, M3 in one patient, M4 in three patients, and M5 in three patients. Of these, four patients had persistent insensitivity in the dorsum of the foot, while six patients had protective sensation, and three patients had normal sensation. Two patients with inadequate anterior tibial muscle strength following nerve repair underwent posterior tibial tendon transfer for restoration of foot dorsiflexion. The greatest functional improvement was obtained in cases in which neurolysis was performed; patients undergoing primary repair had better outcomes compared to those where nerve grafts were used. The results were better in thigh level injuries than those in the gluteal region. CONCLUSION Low expectations after sciatic nerve repair in the past are now being rapidly replaced by a more optimistic approach. Advances in microsurgery and use of treatment algorithms based on scientific research account for this significant improvement in outcomes after sciatic nerve surgery. Tendon transfers can enhance the success rate and be combined with nerve repair in selected cases.

Use of free serratus anterior muscle slips for the reconstruction of dorsal-side defects of the hand resulting from hot press injury.

Mutilation of the hand as a result of hot press injury, the common characteristics of which are extensive soft tissue and extensor tendon loss, metacarpal and phalangeal necrosis, exposition of multiple joints, and infection, presents a serious challenge to the hand surgeon. Free transfer of the inferior three slips of the serratus anterior muscle is a useful surgical option for the reconstruction of dorsal-side defects in the hand. The versatility of the three separate slips, which are easily divisible for contouring, enables individual reconstruction of the different digits. Long vascular pedicle, low donor-site morbidity, and durability are other advantages. Four male patients with hot press injury of the dorsal side of the hand were treated with free transfer of serratus anterior muscle slips and split-thickness skin grafts. Follow-up period ranged between 5 and 12 years. Late functional and cosmetic results are presented.

The effect of parenteral pentoxifylline therapy on skin flap survival

SummaryThe effect of pentoxifylline as a hemorrheologic agent on skin flap survival has been observed. A caudally pedicled dorsal flap with an ischemic component in rats was used as the model. The flap survival was calculated to be 0.807±0.049 in the control group (n = 15), where flap survival was found to be 0.9713±0.018 in the pentoxifylline treated group (n = 15) (t = 12.19, p < 0.005). In the meantime, living flap length was measured as 9.96±0.72 in the control group, and 11.84±0.18 in the pentoxifylline treated group. With these results, we have come to the conclusion that parenteral pentoxifylline therapy is effective on ischemic skin flap survival in the rat model.

Replantation and triple expansion of a three-piece total scalp avulsion: six-year follow-up.

Total scalp avulsion in three scalp segments is an unusual injury. The authors describe the replantation of three scalp segments in a 15-year-old girl. Replantation of the middle scalp piece was unsuccessful, but a satisfactory aesthetic and functional result was obtained by expanding the same replanted tissue three times. Every effort should be undertaken to save the avulsed scalp, even in a severely damaged situation.

Backup perforator flap derived from a previously transferred musculocutaneous free flap

Reconstruction of the lower leg commonly requires a free tissue transfer after Gustillo grade IIIB‐IIIC injuries and severe postoncological resections, where, free musculocutaneous flaps (MCF) are preferred for their size and robust blood supply. The anastomoses are performed at more proximal levels to keep them away from the trauma zone. This reasonable maneuver causes the distal of the flap to cover the most critical part of the defect. Any marginal necrosis, then, ends in exposure of the bone or implant. Reported here is the use of a perforator flap derived from a previously transferred free MCF as a backup tissue.

Experience with Lateral Arm Flap in Hand and Forearm Defects

The lateral arm flap is currently one of the most frequently used free tissues. Easy dissection, constant anatomy and a long pedicle are the major advantages of this hap. 21 patients who had an upper extremity reconstruction with the lateral arm free flap are reviewed. The aetiology of the defects was electrical burn in 12 patients, thermal burn in 3 patients and trauma in 6 patients. The flap was transferred for distal forearm defects in 15 cases and for distal and volar soft tissue defects of hand in 6 cases. In 19 cases out of 2 1, the flaps were harvested from the ipsilateral limb. In 8 cases the transfers were performed under axillary block anesthesia. All transfers were successful and 4 cases required secondary thinning of flaps. In this presentation, indications and results with lateral arm flap will be discussed.