Serdar Nasir

Crossover replantation and fillet flap coverage of the stump after ectopic implantation: a case of bilateral leg amputation.

A successful case of crossover replantation of the left foot to the stump of the right leg and temporary ectopic implantation of the right amputated foot on the forearm is described. The ectopically implanted right foot was used as a free fillet flap for the late reconstruction of the left leg stump. At the latest follow-up examination, 18 months after the accident, the patient was able to walk independently with a prosthesis on the stump of the left leg. Both the cross-replanted foot and the free filleted foot flap, used for the reconstruction of the left leg stump, have maintained adequate protective sensation. The importance of utilization of amputated parts for functional reconstruction is stressed. Crossover replantations and ectopic implantations should be considered in bilateral amputations for the salvage of at least one extremity.

Partially de‐epithelialised and buried V‐Y advancement flap for reconstruction of sacrococcygeal and ischial defects

Defects in the sacrococcygeal and ischial soft tissues can be treated with gluteus maximus and posterior thigh V‐Y advancement flaps. However, late complications include recurrence and dehiscence of the suture line. Increasing the amount of the soft tissues over the bony prominences and multilayered closure may have an advantage for long‐term durability. We modified the V‐Y advancement technique by de‐epithelialising the medial parts of the flap and burying them under the opposing edge of the wound or the flap. Sixteen patients with various defects of the sacrococcygeal and ischial soft tissues were operated on using this technique. All the flaps healed well with no partial or complete loss of the flap. Three patients developed complications. The main advantage of our technique is the use of healthy tissues to obliterate the dead spaces under the edges of the wound or the opposing flap. In this way, not only the defect in the skin but the defect in the subcutaneous tissue, with its iceberg tip at the surface, is treated effectively. To have an additional layer of tissue between the bone and the superficial tissues provides an extra cushion of soft tissue and avoids putting the suture line directly over the bony prominences. We used this modification safely for both unilateral and bilateral flaps. It could also be used successfully in other parts of the body.

Use of a water-vapour permeable polyurethane film (omiderm) in the non-surgical treatment of aplasia cutis congenita.

Aplasia cutis congenita is characterised by congenital absence of all layers of skin, and most commonly affects the scalp. It is often associated with absence of the bone and dura underlining the defective scalp. In this report, we present the result of use of a water-vapour permeable polyurethane film (Omiderm®) together with absorbant fine mesh gauze impregnated with 3% bismuth tribromophenate (Xeroform®) in the treatment of a cranial defect in a newborn baby of low birth weight, who could not be operated on because of associated medical problems.

Soft-tissue management with immediate free flap transfer in segmental prosthetic replacement of proximal tibia sarcomas

Knee reconstruction with endoprosthesis after tumor resection is accepted as superior when compared with the other methods. But sometimes soft tissue reconstruction would be a challenging problem in this way of treatment. Five patients who were operated for tumor resection in this location, followed by reconstruction were presented with their one‐year post operative results. Four latissimus dorsi and one rectus abdominis myocutaneous free flaps were used in these patients in order to manage soft tissue problems. All patients underwent chemotherapy in postoperative period. All flaps were successful in one year post operative examination. In this report we would like to stress the importance of surgical planning and soft tissue reconstruction of a specific patient population. We think that large musculocutaneous flaps such as latissimus dorsi and rectus abdominis musculocutaneous flaps should be preferred in soft tissue reconstruction of knee region after tumor resection followed by prosthetic replacement. Additionally, this way of treatment is superior when compared to the other methods in order to prevent complications such as prosthesis exposure or infection.

Lower Extremity Transplantation: Concepts, Challenges, and Controversies

Reconstructive transplantation with vascularized composite allografts is an emerging frontier, with more than 200 procedures performed worldwide over the past decade. Lower extremity transplantation may be a superior treatment alternative in stringently selected patients who have failed, rejected, or are ineligible to use conventional prosthetics. Despite its potential for sensorimotor nerve regeneration, proprioception, and reflex feedback control of balance and independent ambulation, early outcomes of lower extremity transplantation have been disappointing due to morbidity or mortality. Broader feasibility of this promising procedure will be realized only if perioperative and immunosuppressive complications are minimized and long-distance neurodegeneration is optimized.

Using linear cutting stapler for gracillis muscle flap splitting in facial reanimation

Free gracillis muscle transfer is preferred mostly for facial reanimation (Zuker, 2015). Transferring the whole segment of gracillis muscle causes thick mass under the face skin and unaesthetically appearance deterioration when muscle was contracted after re-innervation period. Furthermore, anterior third of the muscle was transplanted to provide thin segment used in the face skin. The branches of obturator nerve and flap vessels are to take part in this muscle segment. Harvesting of flap from main segment may result in ropy edges of muscle segment because detached muscle fibrils contract independently. Ropy muscle edges may tear by stitches during flap insertion between the corner of the mouth and front of the ear. Providing proficient smile needs effective muscle contraction which depends on the fact that the transferred muscle length is to be equal to the distance between the front of the ear and the corner of the mouth. This tearing causes difficulty in the arrangement of muscle lengthening between the front of ear and oral commissure. Linear cutter stapler (Ethicon Endo-SurgeryTM Linear Cutters) may be used to harvest flap from main muscle body to have clean-cut border. This staples are usually used in abdominal, pediatric, and thoracic surgeries. Generally, the stapler is used for the resection and transection of organs or tissues. The linear cutting stapler is loaded with two double staggered rows of titanium staples and simultaneously cuts and divides tissues between the double rows. A sharp knife is built into the stapler body. The stapler can be easily operated by complete squeeze of the handles followed by shifting the side knob back and forth (http://www. medicalstapler.com/Linear-cutter-stapler.html). The stitches are knotted with 5 cm intervals to mark the muscle length on the anterior side and then two linear cutting staples are squeezed on proximal and distal edges of anterior third in gracillis muscle (Figure 1A). Two muscle edges are cut and harvested. Rows of titanium staples provide linear muscle edges to avoid ropy edges (Figure 1B). This metallic staples strongly anchor to knots between muscle and inserting area. Furthermore, this

New Modification of the Oldest Flap in Rats to Increase Antigenicity of Transplanted Skin: The Extended Groin Flap Model

Tolerance to composite tissue allograft may allow for widespread clinical use of reconstructive allotransplantation. However, the skin component of composite tissue allograft poses an intractable barrier towards achieving this goal: skin is the most antigenic tissue due to rich representation of immunocompetent cells. Moreover, the immunologic response may increase in proportion to the size of skin. In order to precisely evaluate this correlation in experimental studies, a new skin transplant model with a large skin component will be necessary. In the present study, the authors investigated an extended groin (EG) flap transplant model in rats to test its feasibility in two groups: an anatomic study group and an experimental transplant group. In the former group, EG flaps were elevated on superficial epigastric vessels. The EG skin islands of all flaps were shown to be viable at postoperative day 21. In the latter group, isograft transplantations were performed between Lewis rats (RT11), while allograft transplantations were performed between LBN (RT 1+n) donors and Lewis (RT11) recipients. All EG transplants were viable post-transplant day 200 under cyclosporine A monotherapy protocol. In addition, microangiography of the transplant demonstrated that the entire skin island was supplied by the pedicle of the superficial epigastric vessels (SEV). Moreover, studies with India ink demonstrated dye uptake in all flap components, and histological examination demonstrated the viability of flap tissue. Chimerism level was detected below 1 % at post-transplant day 7. Starting from post-transplant day 21, total chimerism began to increase (0.94 % of RT1n cells), and improved during the follow-up period: at 100 days post-transplant it was assessed at 1.25 % of RT1n cells. EG transplant involves fairly uncomplicated surgery, with a short operation time. These cumulative advantages suggest that it may serve as a new experimental model with a large skin component, and may also be used to ascertain the immunologic differences in the recipient body.

Abdominal Wall Transplant Models

The application of composite tissue allograft (CTA) transplants in clinical reconstruction is parallel with extended knowledge of anatomy, microsurgical skills and development of transplantation immunology. CTAs are composed of multiple tissues, some of which such as skin are highly immunogenic and cause strong immunologic responses. Strong antigenic nature of skin may be related to Langerhans cells, which are powerful antigen-presenting cells. They are leukocytes found in the epidermis as members of immunologic cascade. Large skin components of CTA transplant may cause higher antigenic load as a result of increased surface area of transplanted skin correlating with increased load of Langerhans cells. In clinical abdominal wall transplants, increased rejection episodes were reported compared with other CTA transplant. This complication may correlate to large skin component of these transplants. To evaluate correlation between large skin island flaps and immunologic responses, CTA models with large skin components should be tested in experimental studies. Here we propose a total abdominal wall (TAW) transplant model in rat to test the feasibility of TAW transplantation in two groups: the anatomic study and experimental transplantation group. In anatomic study, TAW flaps were elevated bilaterally on superficial epigastric vessels and replaced. The entire TAW skin islands of all flaps were viable at postoperative day 21. Dye study confirmed that TAW flap was supplied by two vascular pedicles. Data in this group demonstrated that this flap is composed of the largest skin island when compared with other CTA transplant models such as full face, hemiface, limb, and groin flap. In experimental group, isograft transplantations were performed between Lewis rats (RT11) while allograft transplantations were performed Lewis (RT11) donors and LBN (RT11+n) recipients.

A new experimental reversed-flow flap model: tail artery based skin flap on the dorsum of the rat.

Reversed-flow flaps are widely preferred particularly in reconstruction of the defects of distal part of the extremities. To overcome the drawbacks faced during clinical practice of this flap type, experimental models in economical species are required. This study provides a new reversed-flow flap model on the dorsum of the rat which is supplied by the ipsilateral lateral caudal artery. It is designed as a triangle with a 4-cm long base and 5 cm long height and it is well protected from autocannibalization and environmental conditions because of its dorsal location. When compared with the present models, we believe that this simple, reproducible, and practical flap model can be considered as advantageous, and will be preferred by the researchers for future experimental studies in hemodynamics and physiology of reversed-flow flaps.

Congenital Breast Malformations

Congenital breast deformities pose a challenging dilemma in plastic surgery. The expression of the abnormality may be complete, and anatomic components are often missing, deformed, or weakened. Most breasts are naturally asymmetrical. These asymmetries may include discrepancies in breast size and shape, location of the nipple–areola complex, the inframammary fold, or skeletal abnormalities (see Figure 29.1). Breast abnormalities can cause emotional and psychological trauma, resulting in social maladjustment and associated behavioral problems. The majority of patients are young healthy individuals who seek aesthetic restoration of their deformities.