Ömer Berköz

Free pre-expanded lateral circumflex femoral artery perforator flap for extensive resurfacing and reconstruction of the hand

Resurfacing and reconstruction of extensive scars, severe contractures and deformities of the hand are still challenging cases for plastic surgeons. Treatments usually necessitate thin, pliable and broad flaps. Additionally, minimising the donor-site morbidity is an indisputable requisite. The pre-expanded perforator flap technique has been shown to provide extensive, thin and pliable skin with increased vascularity while reducing the donor-site morbidity. Utilisation of free pre-expanded lateral circumflex femoral artery perforator flap in an aesthetic and functional reconstruction of severe post-burn hand deformity is demonstrated. The successful functional and aesthetic outcome that was achieved in the early postoperative period and which still persists after 23 months of follow-up indicates that our technique could be preferably used in the extensive coverage of the hand.

Comparison of Ultrasound-Guided Axillary Brachial Plexus Block Properties in Diabetic and Nondiabetic Patients: A Prospective Observational Study

PURPOSE Patients with diabetes mellitus (DM) type 2 may have subclinical peripheral nerve neuropathy. We performed this study to compare the differences in duration of axillary brachial plexus blocks in patients with type 2 DM and without DM (NODM). Our hypothesis was that the sensory block duration would be prolonged in patients with DM. METHODS A total of 71 patients who were scheduled for elective forearm and/or hand surgery were enrolled in this study. Before surgery, they received ultrasound-guided axillary brachial plexus blocks with a mixture of 10 mL lidocaine 2% and 20 mL bupivacaine 0.5%. After surgery, all patients received 1 g paracetamol every 6 hours as needed. The primary end point was sensory block duration. Secondary end points were motor block duration, time until first pain (numeric rating scale [NRS] 4 or greater), highest NRS pain scores, and rescue analgesic consumption (NRS 4 or greater) through the first 2 postoperative days. RESULTS In all, 67 patients completed the study: 22 in the DM group and 45 in the NODM group. Sensory and motor block durations were longer in the DM group than in the NODM group (mean [range], 773.5 [479-1155] vs 375 [113-900] minutes, and 523 [205-955] vs 300 [110-680] minutes). Time until first pain was 855 (590-1,285) minutes in the DM group and 500 (200-990) minutes in the NODM group. The highest NRS scores were also significantly lower in the DM group at 6 and 12 hours. Paracetamol consumption was lower in the DM group through the first 2 postoperative days. CONCLUSIONS The presence of DM was associated with longer duration of the sensory block after axillary brachial plexus block. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.

A distinctive presentation of diplopodia: a Y-metatarsal combining the extra foot and the extra digit of the main foot.

Diplopodia is a rare congenital anomaly and has been described as extra digits, metatarsals, and tarsal bones that form an extra foot or foot-like structure. Various skeletal deformities and anomalies involving other organ systems can accompany diplopodia. Treatment consists of surgery, splinting, and physical therapy, planned according to each patients specific condition. We present a patient who had diplopodia with distinctive anatomic features (with postaxial polydactyly and without any anomaly of the tibia or fibula) compared with the previously reported cases, and concomitant anomalies, including left renal agenesis and anal atresia.

Effects of microarterial anastomosis torsion on survival of oblique groin flap in rats

Abstract A microanastomosis might tolerate a torsion up to 360°, but the effects of arterial microanastomosis torsion on the survival of the flap it supplies are unclear. The aim of this study was to investigate the consequences of microarterial anastomosis torsion on the groin flap in rats. Forty Sprague-Dawley rats were divided into five groups. An oblique groin flap was harvested as an island flap and a patch-to-side arterial anastomosis was performed with torsion angles of 0°, 90°, 180°, 270°, and 360°. Six of eight flaps in Group I (0° torsion), six of eight flaps in Group II (90°), three of eight flaps in Group III (180°), and none of the flaps in Groups IV and V (270° and 360°) were found to be viable after 1 week. The patency and flap survival rates observed in Groups II, III, IV, and V were compared with those in Group I using Fishers exact test. The patency rates and flap survival rates in Groups IV and V were significantly lower compared with those in Group I. Our data show that skin flaps can survive even if their arterial pedicle is anastomosed with a torsion of up to 180°.

Intraneural angioleiomyoma of the median nerve presenting as a forearm mass: A case report

Angioleiomyoma is a solitary form of leiomyoma which is typically encountered in the subcutis. They are mostly seen in lower extremities, and the upper extremity is the second most common location for these lesions. There are only a few reports about the presence of an angioleiomyoma within a peripheral nerve in the upper extremity. Here we report a 56-year-old male patient who was referred to our clinic after an attempt was made for removal of a forearm mass at another institution. The lesion was encased within the median nerve and there was an unusual hypervascularity around the tumor with numerous vessels entering the lesion. Removal of the tumor without apparent damage to nerve fascicles was possible. Histopathological examination of the excision material revealed an intraneural angioleiomyoma. Following surgery, the patient was free of any functional deficits and no evidence of recurrence was observed at one year follow-up. There is no data regarding recurrence in intraneural lesions due to the lack of a large series. It would not be wrong to recommend spare grossly uninvolved fascicles if the nerve in question is not expendable.

BİRİNCİ PARMAK ARALIĞI KONTRAKTÜRLERİNİN BİLOBE FLEPLER İLE TEDAVİSİ

Amac: Birinci parmak araligi (web) bolgesi el islevleri acisindan buyuk onem tasir. Bu bolgedeki kontrakturlerin giderilmesi icin en sik kullanilan yontemlerden biri isaret parmagi dorsalinden cevrilen transpozisyon flebidir. Bu calismada, dorsoradyal rotasyon flebinin verici alaninda ortaya cikan kontur deformitesini gidermek ve flebin transpozisyonunu kolaylastirmak icin kullandigimiz bilobe flep yontemine ait sonuclari ortaya koymayi amacladik. Gerec ve Yontem: Bu yontem kullanilarak birinci parmak araligi kontrakturu acilmis sekiz hastaya ait tedavi ve takip bilgileri retrospektif olarak incelendi. Bulgular: Bu yontemin uygulandigi sekiz hastalik (toplam on el) serimizde ortalama takip suresi 15,3 aydi. Olgularin takiplerinde onemli bir komplikasyon gorulmedi ve yeterli birinci parmak araligi acikligi elde edilebildi. Sonuc: Dorsoradyal transpozisyon flebinin bilobe olarak modifiye edilmesi bu fleple ilgili verici saha sorunlarini guvenli bir bicimde azaltmakta ve flebin daha rahat transpoze edilmesine olanak vermektedir.

Is the transposition of the nipple-areolar complex necessary in Simon grade 2b gynecomastia operations using suction-assisted liposuction?

Abstract Objective: The aim of this study was to assess the efficacy of suction-assisted liposuction (SAL) in Simon grade 2b gynecomastia and its effect on sternal notch to nipple areola (SNN) distance. Methods: A retrospective analysis was performed on 21 patients with grade 2b gynecomastia who underwent SAL. Preoperative and postoperative SNN distances of the patients were measured, the results were analysed using a Mann–Whitney U test and a p-value <.05 was accepted as statistically significant. Aesthetic results were evaluated by the surgical team considering five criteria: breast size, breast shape, nipple-areolar complex positioning, scarring, and skin tightness of the breast envelope. A 10-point Likert scale was used to assess patient satisfaction with SAL surgery. Results: All of the patients were followed up for an average period of 17.8 months (range = 12–28 months). The mean amount of lipoaspirate was 232 mL per breast (range = 190–310 mL). The mean preoperative SNN distance was 22.3 cm (range = 20–23.5 cm), whereas postoperative was 21.3 cm (range = 19.2–22.8 cm); the difference was statistically significant (p < .05). There was one case of nipple areola necrosis, three hypoesthesia, five persistent pains, and four slight buttonhole deformities. The aesthetic result was evaluated as very good by the surgical team, and the overall patient satisfaction rate in terms of breast shape and volume was 92%. Conclusions: It was concluded that SAL provides a good aesthetic outcome in patients with Simon grade 2b gynecomastia and shortens the SNN distance by 1 cm, but further clinical studies are required to support this conclusion.

The effects of limited adventitiectomy on vascular anastomosis: An experimental study in rats

Abstract Objective: Blockages in anastomotic vessels cause complete loss of free tissue transfer and replanted limb. Many studies have been conducted in the last 30 years to solve this problem. There are insufficient studies dealing with the effects of the limited adventitiectomy done before surgery for sympathetic overactivity leading situations. The aim of this experimental study is to reveal the effects of limited adventitiectomy. Methods: In this study, limited adventitiectomy was performed in a wide area before surgery, and the effect of this practice on the vessel diameter and anastomosis was investigated. Results: Rapidly growing dilatation and increase in vessel diameter was observed, and dilatation continued in the limited adventitiectomy group. Conclusions: The preoperative performed limited adventitiectomy is a useful preparation for super microsurgery. Especially in clinical practice before the free flap surgery, limited adventitiectomy can be applied if the recipient site is expected to have vascular problems.

Restoration of Pronation and Radial Deviation in “The Beggar’s Hand” Deformity by Switch Technique

Objective/Hypothesis: In this study, our aim is to present our results with the “switch technique” in the dynamic restoration of forearm pronation and wrist radial deviation in patients with “the beggar’s hand” caused by obstetric brachial plexus palsy. In the “switch technique,” the tendons of two functional muscles are sectioned at two different levels, and the proximal muscular units are transposed to the presectioned distal tendon ends in a cross fashion. This technique enables the dynamic restoration of the paralytic and complex deformity. Materials and Methods: Eleven obstetric palsy patients (6 male, 5 female) with ages ranging between 5 and 10 years (mean age of 7.6 years) were operated for the correction of supination deformity and ulnar deviation of the wrist. Soft tissue releases were performed at the forearm and the wrist. Extensor carpi ulnaris (ECU), brachioradialis (BR), abductor pollicis longus (APL), and the flexor carpi ulnaris (FCU) muscles were prepared. The ECU tendon was sectioned and disinserted from its insertion whereas the BR tendon was sectioned just distal to the myotendinous junction. The distal end of the BR tendon was rotated around the radius from the dorsal to the volar, and then, it was advanced proximally along the interosseous membrane after being passed through a pulley that was prepared from the distal end of the FCU tendon. The ECU tendon was advanced from the dorsal to the volar, and it was sutured to the BR tendon as a pronator. The APL tendon was sectioned from a proximal level, and the distal end of this tendon was sutured to the proximal end of the BR tendon as a wrist radial deviator. The mean follow-up time was 14 months (4-31 months). Forearm pronosupination, wrist flexion-extension, and ulnar-radial deviation were assessed by goniometric measurements. Results: Mean active forearm pronation was −42.5° preoperatively. After the surgery, 38.75° degrees of active forearm pronation was achieved. Preoperative and postoperative mean active radial deviation values were −7.5° and 10.75°, respectively. All patients reported that they became more capable in activities such as turning pages and holding a mug. Conclusions: The tendons that are used in the “switch technique” are not paralytic, and they are functional. In fact, this is a major difference with classic tendon transfers. With this technique, the original muscle bellies and the routes of the tendons are switched. They are used for impaired targets, and they are reorganized for the restoration of insufficient functions. Correction of the deformity improves the appearance of the limb and the self-confidence of the child and allows the patients to integrate well into the society. These results suggest that selected cases may benefit from restoration of “the beggar’s hand” deformity with the “switch technique” that may produce a critical improvement in functional capabilities.

Pressure sore of the forehead as a complication of middle ear surgery

To the Editor: Pressure sores are lesions caused by unrelieved pressure to any part of the body, especially portions over bony or cartilaginous areas. The formation of a pressure sore is a result of decreased tissue tolerance in the face of applied pressure of a defined duration and intensity [1]. The most frequent sites for pressure ulcers are the occiput, sacrum, ischial tuberosities, trochanters, lateral malleoli, and posterior heels of nonambulatory patients. However, the surgeon must be cognizant that other locations of the body can undergo stress necrosis due to prolonged external pressure. Examples include arms leaning over bed rails, nasal alae due to upward taping of nasogastric and feeding tubes, malar prominences due to inaccurate positioning during surgery, cervical region secondary to prolonged collar usage, and medial thighs due to indwelling urethral catheters [2-4]. Here, we report yet another atypically located pressure sore on forehead region secondary to prolonged and unintervened elastic bandage application following middle ear surgery. A 25-year-old woman was admitted to our plastic surgery clinic with a horizontal scar of 3×12 cm on her forehead (Fig. 1). She had undergone mastoidectomy a year ago for chronic otitis media. An elastic bandage had been applied continuously for 2 days (Fig. 2). A pressure ulcer was observed after its removal. Healing by secondary intention resulted in the aforementioned scar. After evaluation, excision of the scar was offered, but the patient refused it. Therefore, conservative measures were taken with limited success. Pressure sores are most commonly seen in dependent locations of the body in patients confined to bed. However, unusual sites may as well be candidates for iatrogenically induced pressure sore formation, and health care workers Eur J Plast Surg (2008) 31:151–152 DOI 10.1007/s00238-008-0228-0