Süleyman Taş

Intraorbital wooden foreign body: clinical analysis of 32 cases, a 10-year experience

BACKGROUND We aimed to describe herein the clinical features, diagnosis and treatment of intraorbital wooden foreign body injuries. METHODS A case series review of orbital injuries managed at Trakya University Faculty of Medicine between 2002 and 2012 was performed retrospectively. The clinical analysis of 32 intraorbital wooden foreign body injuries was reviewed. RESULTS Among the 32 cases, injuries in 16 were caused by a tree branch, in 10 by a pencil, in 5 by a stick, and in 1 by a bush. With respect to preoperative vision, postoperative vision was improved in 69% of patients. Time lapse from injury to presentation was correlated with the size of the foreign body. The subjects were comparable in etiological factor, and distribution of injury according to orbit was as follows: superior 28%, medial 25%, lateral 22%, inferior 16%, and posterior 9%. Computerized tomography (CT) for foreign body was definitive in 72% (n=23) and suggestive in 28% (n=9). CONCLUSION The diagnosis of orbital wooden foreign body is difficult because it may be missed clinically and from the imaging perspective. If a foreign body is suspected, optimal patient management should be done. Prior to the surgery, imaging modalities should be maximally utilized. A careful preoperative evaluation, imaging studies, which are event-specific, a high index of suspicion, and rigorous surgery and postoperative care are the keys in the management of orbital wooden foreign body injuries.

Preventing graft loss caused by hematoma: experimental study.

Hematoma is a common reason for graft loss. This study was intended to investigate the effects of microporous polysaccharide hemospheres (MPH; Arista® AH; Medafor, Inc.) on graft survival, the effect of MPH on graft loss caused by hematoma, and the correlation between neutrophil accumulation and graft survival. A total of 35 adult male Wistar rats were separated into five groups of seven as follows: control 1, saline, MPH, control 2 (hematoma group), and MPH + hematoma. All graft dressing was removed on the fifth postoperative day and graft survival percentage measured. Histopathological and semiquantitative analysis, including inflammatory cell infiltration and subcutaneous inflammation based on neutrophil count, was performed. Graft survival significantly improved in the MPH group (97.86 ± 1.676) compared with the control 1 (91.14 ± 3.671; P = .004) and saline groups (91.57 ± 4.791; P = .014). There was no significant increase in graft survival in the saline group compared with the control 1 group or in the MPH + hematoma group (19.57 ± 14.707) compared with the control 2 group (20.71 ± 16.869; P > .05). The neutrophil count was highest in the control 2 group (177.43 ± 22.464) and significantly decreased in the MPH group (33. 71 ± 8,674) compared with the control 1 group (66.14 ± 5.872; P = .001) and the saline group (65.57 ± 3.309; P= .001). There was no significant decrease in neutrophil count in the MPH + hematoma group (160.00 ± 27.952) compared with the control 2 group (P > .05). It seems that MPH can increase the graft survival, and there is an inverse relationship between graft survival and neutrophil accumulation.

Depressor septi nasi modifications in rhinoplasty: a review of anatomy and surgical techniques.

The anatomy of the nasal muscles contributes a social harmony in aesthetic rhinoplasty because these muscles coordinate the nose and the upper lip while smiling. Sometimes this coordination can be interrupted by the hyperactivity or variations of these muscles and may result as a deformity because of their dynamic functions and relations with the nose. In our daily practice, we usually perform the rhinoplasty without considering the dynamic functions. When the patients recover the muscle functions after operation and start to use their mimics, such as smiling, the undamaged dynamic forces may start to rotate the tip of the nose inferiorly in a long-term period, correlated with their preoperative function. To avoid this unexpected rotation it is essential to remember preoperative examination of the smile patterns. To manage this functional part of rhinoplasty, we aimed to clarify the smiling patterns or deformities mainly focused on depressor septi nasi muscle in this article. This muscle creates downward movement of the nasal tip and shortens the upper lip during smiling. The overactivity of this muscle can aggravate the smiling deformity in some patients by a sharper nasolabial angle correlated with levator labii superioris alaeque nasi and orbicularis oris muscle activities. The article not only stresses the correction of this deformity, but also aims to guide their treatment alternatives for correlation of postoperative results and applicability in rhinoplasty.

A New Way for Antihelixplasty in Prominent Ear Surgery: Modified Postauricular Fascial Flap.

BackgroundOtoplasty procedures aim to reduce the concha-mastoid angle and recreate the antihelical fold. Here, we explained the modified postauricular fascial flap, described as a new way for recreating the antihelical fold, and reported the results of patients on whom this flap was used. Materials and MethodsThe defined technique was used on 24 patients (10 females and 14 males; age, 6–27 years; mean, 16.7 years) between June 2009 and July 2012, a total of 48 procedures in total (bilateral). Follow-up ranged from 1 to 3 years (mean, 1.5 years). At the preoperative and postoperative time points (1 and 12 months after surgery), all patients were measured for upper and middle helix-head distance and were photographed. The records were analyzed statistically using t test and analysis of variance. ResultsThe procedure resulted in ears that were natural in appearance without any significant visible evidence of surgery. The operations resulted in no complications except 1 patient who developed a small skin ulcer on the left ear because of band pressure. When we compared the preoperative and postoperative upper and middle helix-head distance, there was a high significance statistically. ConclusionsTo introduce modified postauricular fascial flap, we used a simple and safe procedure to recreate an antihelical fold. This procedure led to several benefits, including a natural-in-appearance antihelical fold, prevention of suture extrusion and granuloma, as well as minimized risk for recurrence due to neochondrogenesis. This method may be used as a standard procedure for treating prominent ears surgically.

Giant nevus lipomatosus cutaneous superficialis with intramuscular lipomatosis caused sciatic nerve compression.

Giant Nevus Lipomatosus Cutaneous Superficialis with Intramuscular Lipomatosis Caused Sciatic Nerve Compression To the Editor: Nevus lipomatosus cutaneous superficialis (NLCS) is a very rare disorder that Hoffman and Zuhrelle first described in 1921. It is characterized by accumulation of mature adipose tissue in the dermis. These lesions are usually congenital and remain asymptomatic for the duration of their existence. We encountered a giant NLCS with intramuscular lipomatosis that caused sciatic nerve compression. A 45-year-old man was admitted with a slowly growing, huge mass on the sacral area for 15 years’ duration and numbness in the left leg for 1 month. A physical examination revealed a 50 3 50 cm rubbery, nontender, soft, verrucous tumor (Figure 1A). There were neither café-au-lait spots nor developmental defects. He had complete excision of a 10 3 5 cm tumor on the sacral area 5 years before at an external center. Magnetic resonance imaging (MRI) performed before surgery demonstrated diffuse intramuscular lipomatosis associated with a giant NLCS between the gluteal muscles that extended to the thigh region and compressed the sciatic nerve (Figure 2). MRI measurements of the intramuscular lipoma with an association with NLCS were 50 3 20 3 10 cm. The patient’s medical history and the results of routine laboratory testing were unremarkable. A wide excision was planned due to sciatic nerve compression and discomfort in the patient’s daily life. After wide surgical resection, the defect was closed with a large transposition flap and the donor site was repaired with a split-thickness skin graft. At the 24-month followup, there was no recurrence and no symptom of compression neuropathy (Figure 1B). The histopathologic findings demonstrated fat infiltration from the upper dermis into the deep muscle layers and indicated NLCS with intramuscular lipomatosis (Figure 3). Treatment was deemed unnecessary as NLCS remains asymptomatic; other than cosmesis, simple excision is considered sufficient. There is only one reported symptomatic case of NLCS with compression neuropathy of the ulnar nerve. In this case, the authors performed partial excision and suggested partial excision because of the increased morbidity of total excision. Again, there is only one case of a giant NLCS that describes fat infiltration extension to the deep layer of muscle. In this report, although complete surgical excision was performed, NLCS recurred and reached a huge size. We suggest that MRI be done for detecting any muscular component of NLCS for curative treatment in giant NLCS. To the best of our knowledge, there are only six cases of giant NLCS (over 15 3 15 cm) in the literature, including this report, and two of them have muscular lipomatosis under NLCS. Physicians should be well aware of this very rare condition because early recognition

Severe Facial Dermatitis Following Rhinoplasty due to an Unusual Etiopathogenesis: Rosacea

Cutaneous problems following rhinoplasty are minor, early, and temporary [1]. Usually, contact dermatitis with rash and pustules is observed, caused by the benzoin solution or gum used for increasing the adhesion of the tape. If the tape is applied too tightly, it can cause skin necrosis. Persistent redness and telangiectasia of the nasal skin are late cutaneous problems following rhinoplasty [1]. Rosacea is a chronic erythematous disease of the face, characterized by papules and pustules on the erythematous and telangiectasic regions. It may present with phymatous changes and ocular involvement, affect the central part of the face (especially the chin, nose, cheeks, and forehead), and last for months or years with remissions and exacerbations [2]. Rosacea may be seen at any age, but most commonly it begins between the ages of 30 years and 60 years. Although this chronic disease affects women more often, it is more severe in men and it does not show racial variation. Its occurrence is reported to range from 1.2% to 5.4% in people over the age of 50 years, although the actual incidence is unknown [3]. Here, the author reports severe facial dermatitis following rhinoplasty due to an unusual etiopathogenesis, reviews the relevant literature, and presents clinically relevant conclusions. A 27-year-old woman underwent rhinoplasty surgery using the endonasal technique in February 2014. The patient appeared healthy with normal skin and no signs of acne (Fig. 1). The face was prepared with an iodine scrub. No autologous, heterologous, or foreign materials were used during surgery. PDS and Vicryl (Ethicon, Johnson & Johnson Company, Somerville, NJ, USA) were used as suture material. The nasal vestibules were packed with silicone splint. Nonocclusive Micropore (3M, St. Paul, MN, USA) Medical tape and a thermoplastic splint were applied over the nose. No material, such as benzoin solution or gum, was used for increasing the adhesion of the tape. The patient received prophylactic amoxicillin, 1,000 mg of clavulanic acid (2×1) and a non-steroidal anti-inflammatory drug (8 mg of lornoxicam, 2×1) for five days and was subsequently discharged. Fig. 1 Preoperative appearance. The patient was admitted to my clinic five days postoperatively with extreme naso-facial itching and burning sensations. After the splint and bandages were removed, widespread erythema and exudative bullous lesions were apparent on the nose and cheeks (Fig. 2). The European standard battery patch test, with added hydrocortisone and 3M tape, was performed on the patient, along with a consultation with dermatology, and 1+ sensitivity to the 3M tape was detected. The case was diagnosed as irritant contact dermatitis and treatment with a topical steroid (clobetasol propionate, 2×1) was started. The patient was then re-evaluated, since the lesions did not respond to steroid treatment for five days, and the existing lesions were exacerbated. Fig. 2 Severe facial dermatitis is observed on the fifth day after the operation. After a detailed history of the patient, it became apparent that she experienced flushing and redness on the nose and cheeks once or twice a year, which would disappear spontaneously within one to two days. A preliminary diagnosis of rosacea was considered for the patient, who re-consulted with dermatology, and tetracycline (100 mg, 2×1) was started for one week. Since the patient did not respond to this treatment, retinoic acid treatment (20 mg, 1×1) was started 22 days postoperatively. The patient rapidly responded to treatment with retinoic acid and the lesions disappeared in the second month postoperatively. No recurrence was detected in the six-month follow-up period, and the aesthetic outcome was satisfactory (Fig. 3). Fig. 3 No recurrence was detected in the six-month follow-up period. Following rhinoplasty, minor skin reactions may occur depending on the tape and splint. This is referred to as a contact dermatitis reaction and often is reversible upon removal of the causative agent. However, spider veins and telangiectasia may sometimes develop, which can be exacerbated by the application of steroid injections for treating postoperative edema [4]. Acute contact dermatitis can be induced by irritants or allergens. Irritant contact dermatitis is the most common type, with effects ranging from slight erythema to more serious outcomes as blister formation or skin necrosis. The blisters or erythematous plaques may be limited to the contact area or can extend to neighboring areas, and patients complain of a burning sensation [1,5]. Allergic contact dermatitis is a delayed type IV cell-mediated immunological reaction which occurs against exogenous allergens. It usually occurs between 24 to 48 hours after the contact, but may also be delayed until 14 days. Eruptions can develop into moderate to severe grade erythema and aqueous, crusty, itchy lesions. The diagnosis of allergic contact dermatitis can be confirmed by patch testing. The treatment requires the removal of the causative agent and is followed by cleaning the pustules. The affected area should be irrigated with desquamating soap and topical or systemic steroids and antihistamines should be applied [1,5]. The exact etiopathogenesis of rosacea is not known. According to the last accepted classification, there are four subtypes of rosacea and one variant. These are vascular (erythematotelangiectatic) rosacea, papulopustular (inflammatory) rosacea, rosacea phymatous (sebaceous hyperplasia), ocular rosacea, and variant rosacea [2,3]. The earliest sign of vascular rosacea is recurrent, temporary redness on the face, which gains a permanent character over time. Operations, some foods and drinks (hot tea, coffee, alcohol, chocolate, spices, tomatoes, peppers), emotional situations (anger and anxiety), and environmental factors (saunas, hot baths, warm and hot surroundings, fire, sun, wind, and cold) can aggravate the erythema. In the middle of the face, burning, stinging sensations and light squames may be observed. Telangiectasias, though not important for the diagnosis, can often be observed [2,3]. Though rosacea is a difficult disease to treat, it can be controlled. Primarily, the patients should be made aware of and avoid the predisposing factors that vary individually. The treatment of the condition is difficult and requires a multidisciplinary approach and combination therapy [2,3]. In this study, a condition is presented that can be confused with contact dermatitis in an erythematotelangiectatic rosacea patient during the early postoperative period. This case resulted from the stress of the rhinoplasty operation that impacted pre-existing rosacea that was not preoperatively diagnosed. The topical steroid therapy, which was the initial treatment, aggravated the existing condition. Caution should be exercised in the diagnosis and treatment of these conditions, since they may be confused with one another. To the best of my knowledge, rosacea has not previously been reported as a cutaneous problem following rhinoplasty, despite its incidence rate of 1.2%-5.4%. Since contact dermatitis is often encountered in the early postoperative period, it is anticipated that delays in the treatment of undiagnosed rosacea can be prevented by investigating complaints involving flushing earlier in similar cases.

Spontaneous Rupture of the Extensor Pollicis Longus Tendon due to Unusual Etiology

BACKGROUND The etiology of spontaneous rupture of the extensor pollicis longus tendon includes systemic or local steroid injections, wrist fracture, tenosynovitis, synovitis, rheumatoid arthritis, and repetitive wrist motions. CASE REPORT We encountered a case of extensor pollicis longus tendon rupture with an unusual etiology, cow milking. In this case, transfer of the extensor indicis proprius tendon was performed successfully. At 1 year after surgery, extension of the thumb was sufficient. CONCLUSION It appears that patients with occupations involving repetitive motions are at a high risk of closed tendon ruptures.

An unexpected complication after periorbital tumor surgery in a patient later discovered to have myelodysplasia.

The myelodysplastic syndromes (MDS) comprise a complex group of stem cell disorders that involve the ineffective production of one or more of the myeloid class of blood cells. Patients with myelodysplasia often develop severe anemia and require frequent blood transfusions. One-third of thesepatients have a risk of developing acute myelogenous leukemia, usually within a few months to years of developing MDS. Thrombocytopenia is a common feature of MDS in which platelets mature abnormally. Bleeding in these patients is generally due to thrombocytopenia or intrinsic platelet dysfunction. The size, shape, and granulation of platelets are variable. Platelet aggregation is also impaired. The incidence of MDS is approximately 1 case per 1,000 people per year in patients who are more than 80 years old [1]. We encountered a case of a 94-year-old who presented with basal cell carcinoma (BCC) of the right medial canthus with a normal hematologic work-up and history (Fig. 1A). The preoperative hematologic work-up included a complete blood count, activated partial thromboplastin time, and prothrombin time.The patient had the current lesion for 3 years, and the lesion had been diagnosed as BCC with incisional biopsy 1 month before. She underwent excision with a wide margin (at least 5 mm of skin clearance) and full thickness, and immediate reconstruction with a forehead flap. Hemostasis was meticulously performed during the procedure. Within 4 hours of the operation, exaggerated ecchymosis, edema, and hematoma under the flap were observed (Fig. 1B). The hematoma was drained immediately, and the hematologic work-up was evaluated and detected to be above the minimum threshold. The bleeding time was prolonged (more than 10 minutes) clinically. A hematology consultation was requested, and the recommendations were performed. Based on a peripheral blood smear, MDS was diagnosed for the first time. Thirty units of platelet suspensions were given until the bleeding time reached the normal level (Table 1). Daily blood tests were repeated for 2 weeks postoperatively, and the signs and symptoms of bleeding and wound complications were observed closely. At the 3-week follow-up, the flap and the wound had a satisfactory appearance and had healed uneventfully, and the patient had no further bleeding episodes (Fig. 1C). Fig. 1 Views preoperatively (A), 4 hours postoperatively (B), and at 3-week follow-up (C). Table 1 A summary of the clinical situation in accordance with bleeding time and platelet level Clotting disorders are an important cause of flap failure in reconstructive surgery. In patients with thrombocytopenia or an increased bleeding tendency, postoperative flap complications are well known [2,3]. The existing literature lacks reports of MDS patients undergoing reconstructive surgery, with only one report mentioning this clinical scenario. Murphy et al. [4] reported reconstruction of an extensive periorbital defect secondary to mucormycosis by free flap in a patient with previously diagnosed MDS. In this case, thrombocytopenia was controlled with thromboelastography (TEG). They concluded that the low platelet count implied a high complication rate. However, our case had normal platelet levels and underwent a minor intervention; this demonstrates that platelet dysfunction should be kept in mind in MDS treatment. In addition, this clinical scenario makes it difficult to diagnose MDS because a preoperative blood test cannot detect platelet dysfunction. It can only be determined by bleeding time test, thromboelastometry (TEM), and TEG, but these are not among the routine preoperative tests [5]. The authors suggest that in older patients, prior to surgery, a simple bleeding time test should be performed, even if the results of the laboratory tests are within the baseline values. If MDS is suspected, a hematology consultation and peripheral blood smear should be requested to search for MDS, or viscoelastic whole-blood assays such as TEM and TEG should be performed if possible, regardless of the size of the surgical intervention. Thus, the bleeding complications can be avoided, and the number of blood transfusions can be reduced. Nevertheless, if there is no possibility of TEG, a close monitoring of the bleeding time for detecting the amount of transfusion is still helpful. Lack of experience can disrupt the provision of an optimal treatment plan for MDS patients. Upon the recommendation of hematologists, frequent platelet transfusions were given and a satisfactory outcome was achieved. This report proves the importance of closely monitoring the bleeding time and bleeding tendencies in these patients after surgery.

Penetrating Trans-Orbital Injury from a Brush Handle Lodged in the Infra-Temporal Fossa

The infra-temporal fossa (ITF) contains major vessels and cranial nerves. It is divided into two regions: the retro-styloid region, which includes cranial nerves IX and XII, the jugular foramen, and the internal carotid artery; and the pre-styloid region, which includes the trigeminal and facial nerves [1]. The penetration of trans-orbital injuries is rarely observed in emergency departments, and there are few reports on intra-cranial involvement in such injuries. However, non-projectile penetrating ITF injuries due to foreign bodies are extremely rare [2]. We encountered a 24-year-old male who was admitted at our hospital with complaints of right eyeball pain, dizziness, and a foreign body in his right orbital area. His history revealed that he fell on a toilet brush after slipping in the toilet. On physical examination, the brush handle was observed to have entered the globe between the subtarsus and the infra-orbital rim, with minimal bleeding at the wound margins (Fig. 1). Mouth opening was limited. Although the patient was unable to open his right eye, forced lid elevation revealed mydriasis. The right globe was inferiorly fixed, and ocular movement was limited in all directions. The object pressed the globe. Although hypoesthesia was detected in the area of the infra-orbital nerve, no step deformity was detected on the orbital rim upon palpation. Visual acuity could not be evaluated because of the brush handle. A direct lateral graphic view and computerised tomography (CT) revealed a remarkable foreign body, 13 cm in length, lodged in the ITF and projecting into the floor of the right orbit. This caused a blowout fracture of the orbital floor of the right orbit and the posterior lateral wall of the maxillary sinus (Figs. 2, ​,3).3). Radiological images revealed no major vascular injury; however, the tip of the foreign body was close to the carotid canal and jugular fossa. ITF exposure may cause serious complications because of the foreign bodys proximity to significant neurovascular structures. Because the object pressed the globe, we proceeded to the operating room for a simple procedure to withdraw the object immediately. Fig. 1 Photograph of the patients eye upon entering the emergency room. Fig. 2 Head radiograph from lateral perspective; the red arrow indicates the head of the object, and the blue arrow indicates the end of the object. Fig. 3 Computerised tomography (CT) image; the red arrow indicates the tip of the foreign body lodged in the infra-temporal fossa. The outside handle of the object was cut off with an electronic saw to create a sterile environment. Subsequent gradual, simple intraoperative CT-guided withdrawal of the object did not cause any neurovascular damage. Endoscopy was used to help control bleeding through the wound. The globe was observed to be intact. The orbital floor was exposed through a subciliary incision; an approximately 4-cm2 defect was detected and repaired with a Medpor implant. Systemic and local antibiotic therapy (cefazolin 1 g, 3×1; tobramycin drops, 4×1) was started preoperatively and was continued until the wound healed completely. The patient recovered completely in 2 weeks. At the 6-month follow-up, the results were satisfactory; the control CT and magnetic resonance-angiography results were normal (Fig. 4). Fig. 4 Six months after the operation; the results were satisfactory. In ITF injuries, the routes of entry are usually an injury through the maxillary region or the oro-antral region. Jagannathan et al. [2] reported a case of entry of a foreign body through the orbital floor, into the ITF through the posterior wall of the maxilla, without any injury to the conal structures. To the best of our knowledge, the current report is the second case describing this route. To explain this injury mechanism, we speculate that when a forceful blow is encountered in the upward direction, the impact is directly transmitted to the orbital floor without contacting the orbital rim or the globe. This occurred because the orbital floor forms an upward slope that is not parallel to the Frankfort horizontal plane, and the globe was saved because of the fluid malleability of the contents of the globe (Fig. 5). Fig. 5 Schematic representing the mechanism of the blowout fracture: In infra-temporal fossa injuries, force is directly applied to the orbital floor without contacting the orbital rim or the globe, and an orbital floor fracture is produced. The big red arrow ... Access to the ITF is difficult. Traditional techniques include anterior (trans-facial) and lateral (pre-auricular and trans-temporal) approaches. The anterior approach presents a poor aesthetic outcome because it results in a large scar on the maxillary region. The lateral approach has a risk of damaging the facial nerve. Endoscopes allow surgeons to access the human body with relatively little surgical exposure, resulting in less tissue disruption. Endoscopic techniques decrease morbidity by decreasing surgical dissection [3]. It has been reported that simple withdrawal, performed in the operating room, causes no untoward effect [4]. However, a thrombotic carotid obstruction has been reported following the simple withdrawal of a foreign body from the ITF because of the external compression of the local hematoma and scar tissue formation [5]. Therefore, after a physical examination and radiological investigations, we decided that a careful intraoperative CT-guided withdrawal of the object and the use of an endoscope to control bleeding would be more reliable. The satisfactory result of this case supports the assertion that this line of management is appropriate in such injuries. In this injury, the primary response is to perform preoperative steps (e.g., quick transportation to the hospital, radiological imaging, and patient elevation). In addition, an emergency operation should be planned considering the pressure on the globe and the optic nerve. In other kinds of blowout fractures and trans-orbital penetrating injuries, the operation is generally performed after the resolution of the edema. Otherwise, blindness is inevitable. In our case, we recognised this situation and achieved favourable outcomes. From our experience, we suggest that excellent visualisation by intra-operative CT before removing the foreign body along with attempts at bleeding control by an endoscope after the above-mentioned removal should be performed to avoid damage to the intra-orbital and ITF structures. Knowledge of anatomic relationships at the ITF is critical in such injuries; emergency medicine physicians should not attempt to withdraw foreign bodies themselves but should consult maxillofacial surgeons. Trans-orbital penetrating injuries should be treated by using up-to-date technical developments such as endoscopy and intra-operative CT in order to increase safety. We believe that this is the most conservative and appropriate approach for such injuries.