Selcuk Isik

Long-term outcomes of ultra-thin porous polyethylene implants used for reconstruction of orbital floor defects.

Purpose:The objective of this article is to present the long-term outcomes of ultra-thin polyethylene implants used for orbital floor reconstruction in facial trauma patients. Materials and Methods:From 1998 to 2004, 38 patients underwent orbital floor reconstruction with porous polyethylene implants with a mean follow-up of 4 years. A subciliary incision and preexisting facial wounds or scars were used. The boundaries of the maxillofacial injury and the orbital volumes of both orbits were assessed by computed tomography images obtained pre- and postoperatively. In all patients, ultra-thin porous polyethylene implants in various sizes were used to reconstruct the orbital floor defect. Results:None of the patients needed removal of the implants during the follow-up. The volume increase of the traumatized orbits ranged from 0.04 to 6.18 (average 3.12 ± 1.48) mL compared with the intact orbit (P < 0.01). This difference was not significant postoperatively (P > 0.01). Postoperative ectropion in three cases was corrected under local anesthesia. Persistence of complications were as follows: enophthalmos, 3 in 28; diplopia, 1 in 16; dystopia, 1 in 4; and infraorbital nerve hypoesthesia, 3 in 31. One patient underwent late enucleation of the globe because of initial penetrating trauma. Conclusions:We recommend the use of ultra-thin porous polyethylene implants in the reconstruction of the orbital floor defects in facial trauma patients. The implants are durable in the long-term and mimic the anatomy of the thin orbital floor and avoid the morbidity of autogenous bone grafts.

Treatment modalities for post-burn axillary contractures and the versatility of the scapular flap

Inappropriate treatment of axillary burns frequently results in adduction contractures. In this clinical study we have reviewed 32 patients with different types of axillary post-burn adduction contractures. We have used a variety of surgical treatments for reconstruction of axillary contracture releasing defects such as simple grafting, Z-plasties and locally pedicled flaps. Among these alternatives, we preferred to use scapular island flap most frequently. In addition to conventional harvest of this flap, extension of its pedicle up to the subscapular ramification by passing it through the triangular space allowed its transfer even to the anterior axillary line defects in a vertical orientation without pedicle kinking. In conclusion, the island scapular flap is a good choice for reconstruction of all types of axillary contracture, releasing defects with satisfactory results in terms of function and cosmesis.

Pain relief during dressing changes of major adult burns: Ideal analgesic combination with ketamine

Pain management during burn dressing changes is a critical part of treatment in acute burn injuries. Although several treatment options have been suggested, it is still a challenge in a clinical setting. This study is aimed at finding out an ideal analgesic, sedative and/or anxiolytic combination that would minimise the unwanted effects of ketamine. A total of 24 patients, with burns up to 20-50% of total body surface area (TBSA), were included in the study and randomly divided into three groups. In group I, 2 mg kg(-1) ketamine was administered. In group II, 1 mg kg(-1) tramadol was administered and 30 min later, 1 microg kg(-1) dexmedetomidine and 2 mg kg(-1) ketamine was administered. In group III, 1 mg kg(-1) tramadol was applied and 30 min later, 0.05 mg kg(-1) midazolam and 2 mg kg(-1) ketamine was administered. The evaluation was performed with cardiopulmonary monitoring, sedation and visual analogue pain scores and overall patient satisfaction. Any adverse effects of ketamine were recorded. The results showed that group II had better outcomes with respect to pain management during dressing changes. As a conclusion, the use of the combination of ketamine, tramadol and dexmedetomidine was found to be a good treatment option for the prevention of the procedural pain suffered by adult patients during dressing changes.

A retrospective analysis of 101 zygomatico-orbital fractures.

A 5-year review of 101 cases of zygomatico-orbital fractures is presented. The epidemiology, fracture patterns, treatment modalities, and complications were evaluated in this retrospective study. A majority of fractures were sustained by males and resulted from trauma inflicted during altercations and traffic accidents. The most common fracture pattern was tripod fracture and the most common associated facial fractures were mandibular fractures. Open reduction and rigid fixation was the most frequently employed treatment modality. Depending on the stability of reduced zygoma, one, two and three-point fixations were applied. Orbital floor exploration was performed in 41 cases. Ten out of 16 orbital floor bone defects required reconstruction. In these cases orbital floor was reconstructed with 1.5-mm porous polyethylene implant. Although we encountered a few complications related to the incisions for open reduction, the rate of complication in which correction was difficult (e.g. facial asymmetry) was lower with this approach when compared with the literature.

Continuous brachial plexus blockade for digital replantations and toe-to-hand transfers.

Microsurgical operations of the hand are common procedures of reconstructive surgeons. Sympathetic blockade of the vessels provides increased blood flow to the injured extremity, which increases the success rate of the surgery. Moreover, postoperative pain management can be performed with continuous blockade of the nerves. In this article, the effect of continuous brachial plexus blockade on patients who underwent upper extremity microsurgical operation was evaluated. A total of 16 patients were operated on either for replantation or for toe-to-hand transfer. The first group (n = 9) received combined continuous brachial plexus blockade and general anesthesia, and postoperative pain management was performed with continuous brachial plexus blockade. The remaining 7 patients operated on general anesthesia and conventional pain management. All transplant and replants were followed by use of Doppler flowmeter. Pain was scored by visual analog scale every 4 hours postoperatively. Continuous brachial plexus blockade was found to be effective in both sympathetic blockade and postoperative pain management. Continuous brachial plexus blockade must be considered when microvascular anastomosis is performed at the upper extremity, especially at the digital vessels, which are very susceptible to vasospasm.

Versatility of the medial plantar flap: our clinical experience.

&NA; The medial plantar flap presents an ideal tissue reserve, particularly for the reconstruction of the plantar and palmar areas, which require a sensate and unique form of skin. In the past 5 years, the authors performed 16 free flaps, 10 locally pedicled flaps, and five cross‐leg flaps on 31 patients for the reconstruction of palmar and plantar defects. All flaps transferred to the palmar area survived, providing good color match and sufficient bulkiness. The overall results were satisfactory in terms of function and sensation, and no complications related to flap survival in the plantar area were observed. All flaps used to cover defects in the heel and ankle region adapted well to their recipient areas, and all lower extremities remained functional. Because the medial plantar flap presents glabrous, sensate skin with proper bulkiness and permits the movement of underlying structures, the authors advocate its use and view this procedure as an excellent alternative in the reconstruction of palmar and plantar weight‐bearing areas. (Plast. Reconstr. Surg. 109: 1007, 2002.)

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.

Cerium nitrate treatment prevents progressive tissue necrosis in the zone of stasis following burn

Cerium nitrate (CN) was used as a topical antiseptic agent for the treatment of burn wounds and found to reduce the number of anticipated death in burn. This decreased burn related mortality cannot be explained by the control of wound infection alone. In the studies performed to elucidate the unexplained effects of CN treatment, it was shown that CN treatment reduced the alarm cytokine levels, decreased leukocyte activation, reduced macromolecular leakage and finally burn edema formation. We hypothesized that CN treatment prevents the conversion of the zone of stasis to progressive tissue necrosis by decreasing leukocyte activation and reducing macromolecular leakage and burn edema. This was investigated on a well-described burn comb model in the rats. Fifty-four rats were randomly divided into control and CN treatment groups. Each rat in CN treatment group received 0.04 M CN bathing 30 min after burn whereas rats in control group received 0.09% saline bathing. Viability of zone of stasis is assessed with (99 m)Tc-sestamibi scintigraphy. Nine rats in each group were scintigraphically evaluated at the 3rd and 7th day after burn and remaining 9 rats had macroscopic and histological examination at the 21st day after burn to confirm the scintigraphic results. In CN treatment groups, the scintigraphic uptake ratios were higher both at post burn day 3rd and 7th when compared to that of control groups. This was statistically significant (p≤0.05). In the CN treatment group, the results of the average percentage of the re-epithelialization in the zone of stasis were higher than that of control groups. The difference between the groups was also statistically significant (p≤0.05). These results were accepted that CN treatment prevents progressive tissue necrosis in the zone of stasis. This study further elucidates the unexplained effects of CN treatment on burn.

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.

Lower Extremity Salvage Using a Free Flap Associated With the Ilizarov Method in Patients With Massive Combat Injuries

Nine patients with massive combat injuries of the lower extremities were treated with Ilizarov bone transport in conjunction with free muscle flap coverage. In 4 patients soft-tissue coverage was applied first, and distraction osteogenesis was initiated 4 to 6 weeks later. In 3 patients both methods were applied simultaneously, and in 2 patients soft-tissue coverage occurred after distraction. The bones healed well, and all flaps survived. The segmental defects ranged from 8 to 16.5 cm in greatest dimension. The total disability time from initial injury ranged from 16 to 25.5 months. In all patients, full union of the tibia was achieved, and no osteomyelitis occurred. However, in 2 patients the applied flap became depressed, necessitating another flap operation. Despite late treatment in all 9 patients, successful results were obtained. Maintaining the original length of the tibia and providing timely, definitive treatment offer the best outcome for repair of massive injuries of the lower extremities. The Ilizarov transport method, used in combination with muscle flap coverage, represents an effective therapy for repair of massive injury of the lower extremities.