Nazım Gümüş

Negative pressure dressing combined with a traditional approach for the treatment of skull burn

Deep burns of the calvarium due to high-voltage electrical current present serious therapeutic challenges in the healing. In this study, as an alternative approach to the treatment of burned skull, negative pressure dressing is used to facilitate separation of the necrotic bones from healthy margins of the cranium, and to encourage rapid granulation tissue formation after trephination of the bone. A 36-year-old male patient, who had been seriously injured on his head with high-voltage electrical current, is presented. On the fifth day after injury, necrosis of the scalp became clearly significant, thereby necessitating extensive debridement. Under general anesthesia, necrotic scalp was removed, leaving the calvarial bone exposed, and while devitalized calvaria was left in place, exposed bone was drilled. A vacuum-assisted dressing was then applied to the wound and set to 125 mmHg continuous pressure. Some granulation tissue developed in the holes and margins of the wound, but it was not sufficient to allow successful closure of the wound with skin grafting. Therefore, the patient underwent another operation in which devitalized outer table of the skull was easily removed from viable bone by using a little force. Elevation of the necrotic outer bony layer revealed profuse granulation tissue formation over the inner layer. When dealing with this experience, vacuum-assisted dressing seems to be a useful tool in acceleration of the separation of necrotic bones and stimulation of granulation tissue formation in burned calvarium.Deep burns of the calvarium due to high-voltage electrical current present serious therapeutic challenges in the healing. In this study, as an alternative approach to the treatment of burned skull, negative pressure dressing is used to facilitate separation of the necrotic bones from healthy margins of the cranium, and to encourage rapid granulation tissue formation after trephination of the bone. A 36-year-old male patient, who had been seriously injured on his head with high-voltage electrical current, is presented. On the fifth day after injury, necrosis of the scalp became clearly significant, thereby necessitating extensive debridement. Under general anesthesia, necrotic scalp was removed, leaving the calvarial bone exposed, and while devitalized calvaria was left in place, exposed bone was drilled. A vacuum-assisted dressing was then applied to the wound and set to 125 mmHg continuous pressure. Some granulation tissue developed in the holes and margins of the wound, but it was not sufficient to allow successful closure of the wound with skin grafting. Therefore, the patient underwent another operation in which devitalized outer table of the skull was easily removed from viable bone by using a little force. Elevation of the necrotic outer bony layer revealed profuse granulation tissue formation over the inner layer. When dealing with this experience, vacuum-assisted dressing seems to be a useful tool in acceleration of the separation of necrotic bones and stimulation of granulation tissue formation in burned calvarium.

A new approach to closure of myelomeningocele defect: z advancement-rotation flap.

Because myelomeningocele defects vary in size, shape, and location, no single procedure applies to all. A large number of techniques have been described for closing the back defects occurring after excision of the meningocele sac, but new studies focus more on simple, reliable, and versatile alternatives because large defect is a challenging problem for reconstruction. This study presented a new fasciocutaneous flap, called z advancement-rotation flap for the coverage of meningomyelocele defects with the successful outcomes of 11 patients. Meningocele defect is imagined as a rhombus shape placed vertically over the midline and accepted to have corners and angles of a rhombus, but any skin excision from the margins of the wound is not made for creating a defect, which will be completely similar to a rhombus so that its angles are obtuse and real appearance is elliptic or round. Flaps are elevated from both sides of the wound and can easily be advanced, then rotated to the midline, and the donor area can be primarily sutured with no complications. Defect sizes ranged from 7.5 × 6 to 12 × 9.5 cm, and mean operation time for flap elevation and closure was 29 minutes. Presented technique is not only simple, safe, and stable but also has got some more advantages such as short operation time because of easy dissection, minimal blood loss, and primary closure of the whole wound as well. It seems to be an alternative for safe, rapid, less bleeding, and easy surgery resulting in a solution for the closure of large meningomyelocele defects.

Capsular calcification may be an important factor for the failure of breast implant

Nowadays, breast augmentation is one of the most common aesthetic surgical procedures in plastic surgery practice, but is not entirely free of complications, such as haematoma, seroma, implant displacement or rotation, capsular contracture, rippling, disfigurement, perforation and calsification in both early and late implantation period. Perforation of the implant by way of tears or leakage, namely bleed, may be considered as an end point of all complications, leading to end of the life span of the prosthesis in vivo and subsequently needing explantation. Implant rupture is commonly caused by manufacturing defects in the product, deterioration of the implant shell with time and trauma; however, other reasons investigated in many studies have also been claimed to lead to rupture, including severity of the fibrous capsule around the implant according to the Baker’s score, closed capsulotomy or other surgical procedures, implant generation, mammography, manufacturer, location, filler material, texture, size and massage. Presented here is a possible new reason for implant failure with a ruptured breast implant involving severe calcification, suggesting that calcification of either implant shell or fibrous capsule is capable of developing implant failure with tears or leakage in the older implants over time. A 39-year-old patient presented with a left breast deformation affecting the symmetry between her breasts. On attending the clinic, she wanted symmetric breasts with complete correction of the left breast deformation. For her breast asymmetry, she had undergone an operation 19 years earlier for correction of mastopexy in the right breast and augmentation in the left, which recieved a 250-cc, gel-filled implant. On examination of the left breast, which was previously augmented subpectorally with gel implant, significant capsular contractures, namely Baker’s score 3; deformation of the projection of the breast and displacement of the implant laterally and inferiorly, were observed, suggesting a rupture or bleeding of the implant (Figure 1a).

A versatile modification of dermoglandular hammock flap for mastopexy: extended hammock.

Abstract Breast ptosis commonly develops in response to ageing and breastfeeding. Clinical studies now focus on both filling the upper pole of the breast with parenchymal flaps and long-term maintenance of the breast projection without recurrence of upper pole concavity and a significant change in breast shape over time. This study presents a modification for a well-known mastopexy technique, the dermoglandular hammock flap, which provides not only autoaugmentation for the breast but also suspension for the breast parenchyma. This technical modification involving a hammock flap extended in both width and length dimensions, was performed in 17 patients aged 28–43 years with an average age of 31 years. They had minimal, moderate, and severe ptosis. Of these, eight patients had mastopexy only without needing any resection of the breast tissue. In four patients, there was significant asymmetry, needing excision of the breast tissue. In five patients, it was necessary to resect less than 290 g of glandular tissue from both breasts to provide enough reduction of the breast volume. There were no severe complications either in the early or late postoperative period, such as nipple-areolar necrosis, haematoma, infection, or dehiscence of the suture line. However, in one patient, skin depression developed at the end of the vertical scar line in one breast. In the follow-up, medial and upper pole fullness of the breast maintained without recurrence of the ptosis, providing satisfactory shape and projection. With this modification, dermoglandular suspension flap turns to be a more effective procedure and suitable for all types of ptosis. As the sagged lower pole of the breast is used as a flap behind the nipple-areola complex and upper pole, it makes not only parenchymal reposition, but also autoaugmentation in the breast, leading to successful breast fullness.

Lipoma due to chronic intermittent compression as an occupational disease.

A total of 15 coppersmiths who do the job as a traditional profession in Kahramanmaras Province were retrospectively analyzed for revealing a possible relationship of lipoma formation and chronic compression, as the work characteristic related to mechanical pressure to the right thoracal and shoulder region. The workers were examined and their historical data were noted. Chronic compression sites in the patients were also evaluated by magnetic resonance imaging and ultrasonography. The ages were between 30 and 52 years. Body mass index ranged from 18.6 to 38.8. Five were operated for visible lipomatous masses at their injured sites. All of the specimens were reported as containing mature adipocytes. An increased subcutaneous fat thickness at the injured sides of the patients was seen when compared with the uninjured contralateral sides using ultrasonography. At the magnetic resonance images, no capsule intensity was observed in the lipomatose masses. Subcutaneous fat of injured right mammarial regions was thicker than the other contralateral sides in all of the cases. The most prominent lipomas were seen in obese workers, and strong evidence for chronic trauma and lipoma formation as an occupational disease was obtained from the study.

Otoplasty with an unusual cartilage scoring approach

Abstract Background: An ideal otoplasty procedure should minimise the possible risk of severe complications of otoplasty and provide a good aesthetic outcome; however, there is no standart technique to be applied to all types of auricular deformities in different populations. The aim of this study was to present an otoplasty technique with posterior approach in which small incomplete cartilage incisions and suture fixations were used to form the auricle without a need for anterior skin incision and dissection. Methods: This study involved 42 patients who had bilateral prominent ears with unfurled antihelixes associated with or without conchal excess. The otoplasty procedure mainly consisted of a posterior skin excision, incomplete cartilage incisions in the shape of greater mark, “>”, mattress sutures of the posterior cartilage, earlobe correction, and conchal reduction if necessary. Results: This otoplasty technique consists of easy, simple, and rapid surgical steps without a need for anterior skin dissection and cartilage scoring, so it has a low rate of complications in both early and late postoperative periods. Follow-up time of patients ranged from 1–9 years, with an average of 3 years. No major complications such as haematomas, chondritis, wound infection, skin necrosis, asymmetry, recurrence, hypertrophic scars, granulomas, or irregularities developed in the early and late postoperative periods. A good symmetry and natural appearence were achieved with this otoplasty technique. Patients were satisfied with the results. All over complication rate in the postoperative period was 7%. Conclusion: The presented technique overcomes the drawbacks of anterior skin dissection and anterior scoring, and minimises the risk of severe complications such as anterior skin necrosis, cartilage necrosis or destruction, and ear irregularities. It also reduces the operation time, swelling, bruising, and possibility of suture extrusion and recurrence.

Water jet for early treatment of chemical burn.

The first necessity in the initial management of burn to remove from the wound the agent of burn and also any contaminants, clothes or foreign bodies. This is particularly important in chemical burns, because the agent may penetrate deeply into the skin and cause ongoing tissue destruction unless it is immediately and completely removed by washing or irrigation using saline or water. It is well known that irrigation with water is the most effective way both to neutralise and to remove chemical agents; however, some compounds may penetrate the epidermis and may remain after irrigation, so that tissue damage progresses. Complete removal of necrotic skin and tissue as soon as possible is the next step in burn treatment. This accelerates wound healing with or without dermal substitutes, particularly in superficial injuries. Debridement ideally removes all necrotic tissue in a single procedure, leaving behind viable undamaged tissue. This improves the quality of healing in firstand second-degree burns, and minimises the need for further wound revisions. The water jet system, based on fluid jet technology, has been advocated as an alternative to standard surgical excisional techniques for burn, The water jet is capable of adequately debriding superficial and partial-thickness wounds [1–4]. In this article we report on the use of water jet hydrosurgery in the early treatment of a hydrochloric acid burn.

Reuse of skin graft patches for the coverage of skin defects.

A skin graft contains squamous epithelium, which spreads in a radiating outward fashion on the wound surface. This movement of epithelium results in the healing of a defect area. Split-thickness skin grafting is used widely for wound coverage. This type of graft is one of the best alternatives in the repair of large wounds resulting from burn and avulsive injuries, which may affect a large body surface area. The use of mesh techniques in skin grafts can effectively enhance the surface area coverage by epithelization heals the interface of the grafts. On the contrary, a small skin island surrounded with granulation tissue also can produce an epithelization center that heals the defect by epithelization in a radier fashion. At this point, it can be logical to reuse a skin graft patch after its first application to the wound because skin grafts can be taken from their wound bed at 7 to 8 days postoperatively, while the ingrowth of fibrous tissue and vessels into the grafts is continuing. At that time, some epithelization has formed around the original skin graft patch. Therefore, taking a skin patch from its bed after surrounding epithelization has formed allows the patch to be ready to be used again in another area of wound coverage. The same tissue or organs have been used more than once for different surgical aims. Cornea, saphenous vein graft, bone graft, and cardiac valves were implanted again in the same patients because graft disposition, hematoma, stenosis, or other causes required us to resuse skin graft tissue. In this study, a piece of skin graft was used two or three times as a source of squamous epithelium for the coverage of skin defects. Although this reuse is well-known procedure, the literature lacks any information about reuse of skin graft patches for defect coverage. MATERIALS AND METHODS

Management of scar contractures of the hand using Z advancement rotation flap

Functional consequences of hand contractures may lead to extreme impairment in hand functions so repair of the contractures can solve the problems related to hand functions. Different forms of z plasties have widely been used for the release of scar contractures. In this study, a useful z plasty technique, z advancement rotation flap (ZAR) was adapted for the release of hand contractures in the way of using only local tissues. Fourteen consecutive patients who had hand contractures, were treated successfully with z advancement rotation flap technique. They suffered from hand contractures for at least one year which were localized in wep spaces, flexor surfaces of the digits, first wep space, palmar area and extensor surface of the hand. Contractures are all in mild severity, restricting some of the hand motions moderately. In all patients, hand contractures released completely and clinically normal joint motions were achieved, improving extension, flexion and abduction ranges of fingers without any difficulty. All advanced and rotated flaps healed uneventfully. No major complications appeared such as infection, hematoma, suture dehiscence, flap congestion or necrosis. When dealing with this technique for release of hand contractures, it may offer a versatile alternative to well known z-plasty methods used particularly for hand contractures.

Severe influence of early pregnancy on newly reconstructed breast

Since mastectomy may have a devastative effect on the patients appearance, body image and psychology, especially in young women, immediate breast reconstruction is widely preferred to avoid the unpleasant results caused by the defect of mastectomy. Presented here is the case of a 33-year-old patient. Considering her fibrocystic mastopathy, atypical ductal hyperplasia and a history of familial breast cancer, subcutaneous mastectomy and breast reconstruction using an implant was planned with skin reduction and repositioning of the areola-nipple complex. During her postoperative follow-up examinations which were conducted periodically, it was expected that the formation of the breasts in relation to the prosthesis would take place in the healing time. In contrast, an increase in the skin thickness and breast fullness, massive filling in the submammary fold, a vertical suture depression and consolidation were observed. These unexpected deformities were based on a pregnancy beginning just after the last operation. Later, the breast findings were followed both clinically and photographically. After termination of the pregnancy, reduction in the skin thickness, involution of the glandular tissue and changes in the shape of the breasts were observed to continue for 6 months. The end result was the development of an unacceptable breast appearance which required a major revisional surgery. Early pregnancy after subcutaneous mastectomy with reconstruction severely affects development leading to distortions in the shape of the breast during pregnancy. Additionally, involution after delivery is not also good enough to provide acceptable outcomes.