Selman Altuntaş

Morphological and morphometric evaluation of the ilium, fibula, and scapula bones for oral and maxillofacial reconstruction

This study aimed to evaluate the osteometric boundaries of the ilium, fibula, and scapula beyond which reconstruction of oromandibular and craniofacial defects, using these free flaps, may not be optimal. Fibula, scapula, and iliac bones were obtained bilaterally from 33 female and 27 male European adult cadavers (n = 60). Adapting classical anthropometric methods to surgical needs by modifying the measuring bone localizations and measurement points, a measuring system of osteometry and morphometry was used, to quantify the usable bone length of the iliac crest, fibula, and lateral border of the scapula and to localize an oval region (OR) in the ilium. The thin, translucent OR of ilium was localized 6.24 ± 5.6 cm posterior to the maximum concavity between the anterior superior (ASIS) and anterior inferior iliac spine and 2.67 ± 6.0 cm caudal to the intermediate line of the iliac crest. The available iliac crest was measured from ASIS to the posterior superior iliac spine (PSIS) 24.75 ± 12.6 cm, fibula supplied 17.02 ± 19.1 cm harvestable bone, and the lateral border of the scapula 9.43 ± 8.5 cm. The OR influenced the harvestable bone shape and volume of the ilium. Measuring of the localization points of OR, we found that the size of the OR was very variable and that the height of the neomandible reconstructed with iliac crest might alter with aging. Our findings contribute with knowledge of detailed morphometric measurements on commonly used donor bones to the planning strategies of volumetric defects in oral and maxillofacial region by precise osteometric localization method of OR and relativized length measurements.

Fat tissue as a new vascular carrier for prefabrication in reconstructive surgery: experimental study in rats

Several vascular carriers for different tissues were used for the purpose of fat tissue prefabrication. However, the inguinal fat pad in rats can be elevated with a vascular pedicle and considered as a vascular carrier. To the best of our knowledge, the fat tissue in rats as a vascular carrier has not been reported in any experimental studies to date. In our study, we aimed to describe a new prefabrication model in rats in which skin prefabrication was accomplished using the inguinal fat pad as a vascular carrier. Inguinal fat pads in rats were elevated over a superficial epigastric vessel pedicle in the pilot study. The contralateral inguinal fat pads were prepared as grafts. After 1 week, we compared the histopathological findings of the inguinal fat pad flaps and grafts and determined that the inguinal fat pad can be safely elevated over the vascular pedicle. In the experimental group, bilateral vascularised inguinal fat pads were transferred to the lower abdomen for skin prefabrication. After 3 weeks, bilateral fat-skin composite flaps including prefabricated lower abdomen skin were elevated over the vascular pedicles. One side was used as a composite flap while pedicle of the other side was transected at its origin at the femoral vessels to create the composite graft. Composite flap and graft were inserted at their original positions. One week later, the composite flaps were stained with India ink, perfused by fluorescein, and filled with contrast material for microangiographic study. In the histological examination, fat and skin tissues of the composite flaps were viable while those of the composite grafts were necrotic. Based on these findings, we can conclude that the fat tissue as a vascular carrier can be successfully used for tissue prefabrication in plastic surgery.

Comparative clinicoanatomical study of ilium and fibula as two commonly used bony donor sites for maxillofacial reconstruction

We assessed the morphological characteristics and dimensions of the ilium and fibula to evaluate the suitability of particular areas of bone for use as donor sites for dental reconstructions that carry implants. We measured the dimensions of 130 bilaterally harvested ilium and fibula bones from 65 adult cadavers using osteometric methods, and analysed the effects of age, sex, and side. Dimensions at measuring points, overall suitability for implantation, and relations among age, sex, and side, were evaluated statistically. We report observations of bone morphology involving cross-sections, and clinical relevance. Although the mean dimensions of the fibula and iliac crest were adequate, some segments would not support an implant 10 mm long and 3.5 mm wide. The overall suitability of parts of the iliac block fell to 30%. Fibular morphology is characterised by constant height and width, and relation of cortical and cancellous bone. Bony dimensions on the iliac fossa and fibula were significantly greater in men than in women. Age had a negative impact in one area of the iliac fossa, but nowhere on the iliac crest. Side was not significant. We found differences in dimensions and morphology between measuring points on the same bone. Precise knowledge about which areas of the donor sites can reliably provide sufficient bone to carry implants after reconstructions will allow greater flexibility and safety when reconstructions are designed.

Morphometric study of the scapular free flap and the free rib osteomyocutaneous flap.

The scapula free flap is often the first choice for reconstruction of bony defects of the facial skeleton. However, the vascularised rib as part of a free rib osteomyocutaneous flap may be a suitable second choice. We have investigated the morphology and clinical dimensions of the 7th rib and the scapula, and the ability of the available bone to carry dental implants. The age and sex of the cadaver, and the donor side, were also recorded. The dimensions of the scapulas and 7th ribs (n=130 of each) from 65 cadavers were measured at 4 different points using osteometric methods. Examination showed that bone from the scapula and 7th rib were sufficient for placement of implants. The 7th rib gave reliable measurements for both height and width, and a consistent relation between compact and cancellous bone. Although the scapula provided adequate compact and cancellous bone, there were variations depending on the segment of bone chosen. Bones from male cadavers were more suitable for implantation. In both the scapula and the 7th rib ageing had a significant adverse effect in only one dimension. Most points of measurement have satisfactory bony dimensions for insertion of dental implants.

Misdiagnosed widespread eosinophilic granuloma of the mandible.

Abstract Eosinophilic granuloma is the most common expression of Langerhans cell histiocytosis and corresponds with typical bone lesions. Early clinical signs can occur in the mandible and can cause extensive destruction of the periodontal tissues. Pathologic fracture is an unusual finding. A case of misdiagnosed eosinophilic granuloma in a 45-year-old man treated with free fibula flap and implant-supported overdenture prosthesis is reported. Free fibula flap with dental implants is a safe and reliable method for comprehensive functional and aesthetic mandibular defect reconstruction.

Hemodynamic Differences in Blood Flow between Free Skin and Muscles Flaps: Prospective Study

We used Doppler ultrasound to evaluate postoperative hemodynamic changes in blood flow in skin (n = 11) and muscle (n = 4) flaps. The minimum velocities, resistance indexes, and diameters of the pedicle, the recipient, and control artery (the corresponding contralateral artery that served as a recipient vessel) were recorded intraoperatively and at 10 days, 1 month, 3 months, 6 months, and 12 months after surgery. The minimum velocities and blood flow in recipient and pedicle arteries in both groups increased after flap transfer. In control arteries, these values decreased over the follow-up period. The decrease of blood flow in recipient arteries for the skin flaps started at 10 days and in the muscle flap at 1 month. The decrease in minimum velocity was noted after 10 days and 1 month for skin and muscle flaps, respectively. Resistance indexes were higher in skin flaps (99 +/- 6) compared with muscle flaps (89 +/- 9). Also, recipient blood flow after flap transfer, independent from intraoperative values, changed according to flap size; muscle flaps that were larger than skin flaps caused significantly higher blood flow in recipient artery.

Risk factors for complex regional pain syndrome in patients with surgically treated traumatic injuries attending hand therapy

Study Design: Prospective cohort study. Introduction: Identification of risk factors for CRPS development in patients with surgically treated traumatic injuries attending hand therapy allows to watch at‐risk patients more closely for early diagnosis and to take precautionary measures as required. Purpose of the Study: The aim of this study was to evaluate the risk factors for the development of complex regional pain syndrome (CRPS) after surgical treatment of traumatic hand injuries. Methods: In this prospective cohort, 291 patients with traumatic hand injuries were evaluated 3 days after surgery and monitored for 3 months for the development of CRPS. The factors assessed for the development of CRPS were age, sex, manual work, postoperative pain within 3 days measured on a Pain Numerical Rating Scale (0–10), and injury type (crush injury, blunt trauma, and cut laceration injury). Results: CRPS was diagnosed in 68 patients (26.2 %) with a duration of 40.10 ± 17.01 days between the surgery and CRPS diagnosis. The mean postoperative pain score was greater in patients with CRPS than in those without CRPS (P < .001). Patients with pain scores ≥ 5 had a high risk of developing CRPS compared with patients with pain scores <5 (odds ratio: 3.61, confidence interval = 1.94–6.70). Patients with crush injuries were more likely to develop CRPS (odds ratio: 4.74, confidence interval = 2.29–9.80). Conclusions: The patients with a pain score of ≥5 in the first 3 days after surgery and the patients with crush injury were at high risk for CRPS development after surgical treatment of traumatic hand injuries. Level of Evidence: II b.

A new total hemiface allotransplantation model in rats

Vascularized composite allotransplantation (VCA), a new reconstructive option for patients suffering from extensive facial defects leads to superior functional and aesthetic outcomes compared to the standard autologous reconstruction. Among VCA recipients, each case involves different facial structures and tissues depending on the patients injury, thus drawing conclusions on the mechanism of immune interactions between the donor and recipient is challenging. This study introduces a new total hemiface VCA model, including scalp, external ear, mystacial pad, premaxilla, upper/lower lids, nose, and upper/lower lips to evaluate the effect of transplantation of multitissue VCA on the recipients immune response.

Thrombotic effect of purposeful back-wall stitch for end-to-side microarterial anastomosis in rats.

The accidental placement of a back-wall stitch is a mistake easily made by microsurgeons during an end-to-side (ETS) anastomosis, which is technically more difficult compared with an end-to-end (ETE) anastomosis. The thrombogenic effects of a back-wall stitch may aggravate the already existing turbulence and therefore thrombus-prone ETS anastomosis. We investigated this dangerous combination by applying a purposeful back-wall stitch model (PBWS) in an ETS microarterial anastomosis model in various configurations the rat carotid and femoral arteries. We performed femoral and carotid artery bypass grafts via two ETS anastomosis. Carotid (n=28) and femoral (n=28) artery groups were equally divided into four different subgroups according to PBWS placement: Control (no PBWS) and 30-degree, 60-degree, and 90-degree subgroups with PBWS located at 30, 60, and 90 degrees, respectively. We found that there were no significant patency differences with respect to vessel type, PBWS placement, or time of assessment. The results of our current study and previous studies demonstrate that a PBWS in the ETS anastomosis does not have a major effect on thrombus formation. We think that an inadvertent back-wall stitch in the ETS anastomosis may not be a significant cause of thrombosis alone but in combination with retained thrombogenic material into lumen can contribute to thrombus.

Rehabilitation of the Work Accident-Related Traumatic Mandible With Iliac Free Flap, Distraction Osteogenesis, and Dental Implants

Mandibular bone defects due to extensive trauma impair occlusion and affect the aesthetics of facial contouring, making it difficult to obtain a satisfactory outcome. Distraction osteogenesis and free flap is an effective and aesthetic treatment option for rehabilating these defects. In this clinical report, the authors present rehabilitation of a wide mandibular traumatic defect due to a work-related accident with iliac free flap, distraction osteogenesis, and dental implants.