Osman Kelahmetoglu

Comparison of free anterolateral thigh flaps and free muscle-musculocutaneous flaps in soft tissue reconstruction of lower extremity

The objective of this study was to compare the free muscle‐musculocutaneous flaps and free perforator skin flaps used for soft tissue reconstruction of the lower extremities.

Comparison of Free Muscle and Perforator Skin Flaps for Soft Tissue Reconstruction of the Foot and Ankle

Background: Free tissue transfer is generally required for reconstruction of soft-tissue defects of the foot and ankle region because of the limited local tissue available. This type of reconstruction may interfere with postoperative function and footwear if a bulky flap is used. Materials and Methods: Twenty-nine patients had free tissue transfers to the foot and ankle region during a period of 3 years. Sixteen had reconstruction with free anterolateral thigh perforator flaps (ALT) and 13 had reconstruction with free muscle flaps. The outcomes of both types of reconstructions were compared according to flap scores and complications, operative time, hospitalization, gait and shoewear problems. Results: The patients in the ALT group were younger compared with those of the free muscle flap group (p = 0.022). The operative time and flap complication rate was significantly higher (p = 0.007 and 0.040, respectively) in the ALT group. ALT was generally used for reconstruction of the dorsal foot, heel and plantar regions. Muscle flaps were preferred in the ankle region, where open fractures of the tibia and fibula were frequently present, and for the patients with increased risk of perioperative morbidity. Conclusion: Free ALT flap consisting of skin and adaptable subcutaneous tissue, both diminishes donor site morbidity and is ideally suited for most soft-tissue reconstruction of the dorsal foot, heel and plantar foot. Free muscle flaps, however, may offer relatively less complicated tissue transfers and are preferred at the ankle region in the presence of open tibia fractures, and in high risk patients to decrease the perioperative morbidity. Level of Evidence: III, Retrospective Case Control Study

Free Anterolateral Thigh Flap for Reconstruction of Car Tire Injuries of Children's Feet

Background: Grade IV and V car tire injuries occurring in children cause extensive soft tissue defects with exposure or loss of tendons and bone on the dorsum of the foot. Free tissue transfer is indicated for reconstruction of these defects because of the limited local tissue available. We describe our management of high-grade car tire foot injuries in children with free anterolateral thigh flap (ALT). Materials and Methods: Five pre-school children with car tire injuries (one grade IV and four grade V) were treated with free ALT flap in the last 4 years. The mean age was 4.8 years. In four patients, immediate flap coverage after initial debridement was performed and delayed reconstruction was used as a secondary procedure in one patient. Results: One of the flaps was re-explored for hematoma evacuation and salvaged. All of the flaps survived completely and there were no donor site complications. None of the flaps required a debulking procedure and custom shoe wear has not been necessary in any of the patients. Minor gait abnormalities were detected in two of the patients. Conclusion: With minimal donor site morbidity, long vascular pedicle allowing anastomosis outside of the trauma zone, we believe free ALT flap provides the ideal soft tissue reconstruction for high grade car tire injuries of foot in children. ALT flap can be further thinned to adapt to the defect, contracts less than muscle flaps and contains a vascularized fascia which can be used for extensor tendon reconstruction. Level of Evidence: IV, Retrospective Case Series

Pedicled perforator flaps.

Described in this study is a surgical concept that supports the “consider and use a pedicled perforator flap whenever possible and indicated” approach to reconstruct a particular skin defect. The operation is entirely free-style; the only principle is to obtain a pedicled perforator flap to reconstruct the defect. The perforators are marked with a hand-held Doppler probe and multiple flaps are designed. The appropriate flap is elevated after identifying the perforator(s). Dissection of the perforator(s) or complete incision of the flap margins are not mandatory if the flap is mobilized adequately to cover the defect. Defects measuring 3 × 3 cm up to 20 × 20 cm at diverse locations were successfully reconstructed in 20 of 21 patients with 26 flaps. Pedicled perforator flaps offer us reliable and satisfactory results of reconstruction at different anatomic territories of the body. It sounds more practical and creative to use a free-style manner during pedicled perforator flap surgery, instead of being obliged to predefined templates for this type of procedure.

Efficient Utility of WhatsApp: From Computer Screen to the Surgeon's Hand to Determine Maxillofacial Traumas.

To the Editor: Advances in communication technologies and mobile phones have been improving rapidly for 10 years. These advances and developed applications (Apps) compatible with smartphones have led them to be a crucial device for their users, especially that apps let people use smartphones like a computer. It is obvious that the smartphones are much more than just a phone. On the other hand, the smartphones are used commonly among doctors too, and there are lots of medical apps. WhatsApp (WhatsApp, Inc., Mountain View, CA) is the most popular instant messaging application for smartphones. The users may send and receive location information, images, video, audio, and text messages in real time to individuals and groups of friends at no cost. We used WhatsApp application as an image and video transfer program to send computerized tomography (CT) sequences between emergency service and plastic surgeons in the night-time consultations on the patients having maxillofacial traumas. For sending and receiving images and videos, the smartphones having both WhatsApp and high-definition camera were used. The physician at the emergency service took the view of CT images from a computer screen and sent the images (Fig. 1A), and serial images were recorded as videos (Fig. 1B) on app. Due to highdefinition cameras on the smartphones, it is possible to narrow and magnify the images. Moreover, sent images or videos did not need any specific programs to run them. It provided us to see the images immediately and to easily determine whether there was fracture. Plastic surgeons get benefits from technological advancements, and it is easy to adopt these advancements to their professional lives. Tele-consultation is a well-known and established way of evaluating patients. It is utilized in the examination of soft tissue injuries and burns at emergency services. For craniofacial traumas, telemedicine was used too. They needed personal computers, remote access to the server, and specific requirements. Although radiographic images such as CT scans may be viewed on smartphones, they need specific interfaces and apps that allow surgeons to view CT scans over a secure network from a remote location. For considering our needs, we thought that during tele-consultation, the fastest, easiest, and most common way should have been used. In our method, the smartphones which have a good quality camera and WhatsApp were used. They are very common recently and are also found in almost all doctors’ pockets. Capturing scan images and recording serial views of scans as a video are easy and do not need any specifications. Moreover, the receiver surgeon does not have to be in front of the computer or at home. Wherever he is, he may get and evaluate the views. It allows us to conclude the consultation rapidly. In conclusion, sending and receiving images and videos on WhatsApp is an easy, rapid way of evaluating of maxillofacial CT scans in the night-time tele-consultation.

Transaxillary-subclavian transfer of pedicled latissimus dorsi musculocutaneous flap to head and neck region.

Free-tissue transfer is the reconstruction of choice for most head and neck defects. However, pedicled flaps are also used, especially in high-risk patients and after failure of a free flap. The aim of this study was to compare transaxillary-subclavian pedicled latissimus dorsi musculocutaneous (PLDMC) flap, pectoralis major musculocutaneous flap, and free-tissue transfer for head and neck reconstruction in American Society of Anesthesiologists grades II and III patients. During the last 4 years, PLDMC flap with a modified transaxillary-subclavian route for transfer to the neck was used in 8 patients, pectoralis major musculocutaneous flap was used in 7 patients, and free flaps were used in 12 patients for head and neck reconstructions. These 3 methods were compared regarding the flap dimensions, complications, flap outcome scores, hospitalization time, and cost of the treatment. Mean age of the patients, mean American Society of Anesthesiologists scores, mean dimensions of the flaps, and mean hospitalization time did not differ significantly among the 3 groups. Regarding the operation time, flap complications, outcomes, and cost of total treatment, although statistically not significant, PLDMC group offered the fastest reconstruction with highest flap outcome scores and minimum cost. Free-tissue transfer is the procedure of choice especially for functional reconstruction of head and neck region. Occasionally, there exist cases in whom a pedicled flap could offer a safer option. The PLDMC flap transferred via the transaxillary-subclavian route may be preferred than, with advantages including increased arc of rotation, safer pedicle location, shorter duration of the procedure, and reduced complication rates and costs.

Spreader flap correction of dorsal septal deviations.

A good rhinoplasty dissection is crucial to identify and release the vectoral forces on a deviated septum before correction.1 Even after completing the dissection, dorsal hump reduction, septoplasty, and osteotomy, there may be persisting septal deviation. A number of techniques have been identified to correct various kinds of deviations that persist after release. Cartilage grafts from the septum itself, or from other regions (concha or ribs), or alloplastic materials are used to correct the dorsum.2 The spreader flap technique (so-called autospreader, turnover flap, or fold-in flap)3 may also be used for this purpose. In this technique, the upper lateral cartilage is separated from the septum and folded medially and dorsally following meticulous dissection of the mucoperichondrial flaps. Longitudinal scoring of the dorsal …

Glans penis reconstruction with the pedicled deep inferior epigastric artery perforator flap.

This is a report on a novel technique of neoglans reconstruction in a patient with an amputated glans penis as a result of a gunshot injury. A pedicled deep inferior epigastric artery perforator (DIEAP) flap measuring 7 x 4 cm and centralizing the uppermost perforators in the right abdominal region was used. The distal penile skin was used to elongate the urethra. A subcutaneous tunnel was created alongside the penis and underneath the mons pubis. The flap was passed through this tunnel, fashioned into the shape of a glans, and secured in place around the neourethra. The patient had a satisfactory neoglans and a functional urethra at 4-month follow-up. The pedicled DIEAP flap is a suitable option for reconstruction of the glans penis.

A simple concept for covering pressure sores: wound edge-based propeller perforator flap†

We present a new surgical modification to allow propeller perforator flaps to cover pressure sores at various locations. We used a propeller perforator flap concept based on the detection of newly formed perforator vessels located 1 cm from the wound margin and stimulated by the chronic inflammation process.

The planning of propeller perforator flap on previously transferred musculocutaneous flap via multidetector computed tomography for the reconstruction of tissue defect overlying Achilles tendon

The mapping of peripheral vascular system and imaging perforators are essential before perforator flap surgery. Magnetic resonance imaging (MRI), Doppler ultrasonography (US), and computed tomography (CT) are widely used techniques to determine the location of recipient vessels and perforators in donor site (Demirtas, Cifci, Kelahmetoglu, Demir, & Danacı, 2009). CT imaging is found to be an effective method for perforator selection at donor site prior to autologous breast reconstruction (Hamdi, Van Landuyt, Van Hedent, & Duyck, 2007). Backup perforator flap was described as the use of a perforator flap derived from a previously transferred free musculocutaneous flap (Topalan, Guven, & Demirtas, 2010). This letter presents the reconstruction of a tissue defect on Achilles tendon using a backup propeller perforator flap, three-dimensional (3-D) CT imaging was used to determine the perforators of previously transferred free latissimus dorsi musculo-cutaneous flap (LDMC). A 35-year-old female patient was referred to our outpatient clinic for a lower extremity tissue defect with a history of right tibial and fibulal fracture fixation due to traffic accident. The patient had serial debridements ending up with a 27 × 17 cm soft tissue defect. Free LDMC flap was performed by using the anastomosis between the donor vessels and the anterior tibial artery and concomitant vein as recipient vessel. On postoperative 4th day, wound dehiscence was noted on Achilles tendon. Wound care was done and prepared for revisional surgery. Prior to reconstruction, LDMC flap perforators were located with multidetector (MD) CT scan (Figure 1A) according to the previously described method by (Hamdi et al., 2007) The findings were evaluated and the optimal perforator vessel was chosen (Figure 1B). A propeller perforator flap was raised and rotated clockwise 150 and adapted to the defect. The flap donor area was