Tahsin Oğuz Acartürk

Commercially available demineralized bone matrix compositions to regenerate calvarial critical-sized bone defects

Background: Demineralized bone matrix products are often used by surgeons to regenerate bone. Several different types of carriers have been combined with demineralized bone matrix to improve clinical handling and surgical outcome. The aim of the study was to quantitate bone regeneration in standard-sized calvarial defects (a critical-sized defect) in response to commercially available demineralized bone matrix formulations. Methods: The commercial demineralized bone matrix formulations were tested as received in 8-mm-diameter calvarial critical-sized defects in an athymic rat model. The demineralized bone matrix treatment groups included the following: (1) Allomatrix; (2) demineralized bone matrix plus sodium hyaluronate (DBX); (3) DBX with poly(DL-lactide) mesh; 4) Dynagraft; (5) Grafton; (6) Regenafil; and (7) human demineralized bone matrix without a carrier. An eighth treatment was a poly(DL-lactide) mesh. At designated times of 2, 4, and 8 weeks, the critical-sized defects were recovered and processed for undecalcified histology and histomorphometry. Histomorphometric data were subjected to an analysis of variance and Fishers protected least significant difference multiple comparison test. Significance was established at p ≤ 0.05. Results: Allomatrix, Dynagraft, Regenafil, and poly(DL-lactide) mesh alone had less bone formation than DBX, Grafton, DBX plus mesh, and demineralized bone matrix. Conclusions: DBX, DBX plus mesh, demineralized bone matrix, and Grafton produced more bone formation than Allomatrix, Dynagraft, mesh alone, and Regenafil.

Laparoscopically harvested omental flap for chest wall and intrathoracic reconstruction.

Minimally invasive surgery has gained popularity in the last decade and its applications to plastic surgery are expanding. Pedicled omental flaps are used for the reconstruction of chest wall defects following debridement of sternal infections and mediastinitis. The main advantages of using an omental flap are its large size and bulk to fill large 3-dimensional dead spaces, long pedicle, and rich vascular and lymphatic networks. Recently, laparoscopic techniques have been described for harvesting omental flaps. Over the last 5 years in our institution, 9 laparoscopic omental flap harvests were performed. Seven were used in the reconstruction of complicated chest wall defects, sternal infections, mediastinal abscesses, and mediastinitis following cardiac surgery. Two were used to repair intrathoracic viscera. Prior abdominal surgery was not a contraindication to the laparoscopic harvest. In 1 patient, the omental transfer was converted to a free flap due to the detachment of the pedicle, and in 1 patient the omental harvest was converted to open technique due to technical difficulty due to severe abdominal adhesions. None of the patients had major intraabdominal complications postoperatively. One patient had a small transdiaphragmatic hernia treated by laparoscopic techniques. The use of laparoscopy techniques facilitated the harvesting of the omentum, making it ideal in the treatment of complicated patients with multiple comorbidities. With these techniques, pedicled omental flaps will be a reasonable treatment option for chest wall reconstruction.

Aesthetic and functional restoration using dorsal saddle shaped Medpor implant in secondary rhinoplasty.

Functional disorders due to alar valve collapse and cosmetic unsatisfactory results can be seen after rhinoplasty operation in some patients. Because of overresection of the upper and lower lateral cartilages, nasal lateral walls may collapse during inspiration pressing against the septum and obstructing airway. On the other hand, overresection may result in several cosmetic deformities. Fourteen patients presenting with nasal deformation and functional insufficiency, were treated using thin sheet porous polyethylene (Medpor). Cottle sign was positive in all patients. On examination, collapse during inspiration, depression at the supratip area, and asymmetry were common findings. Saddle shaped implants, 1.2 × 40 mm in dimension, were introduced into pouches prepared via bilateral rim incision. After suturing incisions, bandage and cast were applied. In the mean 14-month follow-up period, 1 implant malposition was seen in a patient because of larger planning the pocket that was corrected by a subsequent shaving of the implant. Asymmetries of the noses were totally corrected. No exposition was found. Alar collapse and respiration impairment had disappeared in all patients. Although, autologous tissue is known as the best material, Medpor can be used safely regarding its low complication rate because of its porotic architecture and low morbidity in donors. Medpor implant provides functional improvement by its strength body. Its smooth surface helps to correct the asymmetry by filling the defects. Using a saddle shape enabled us to treat different components of the postrhinoplasty deformity with a single implant.

Posttraumatic epidermal inclusion cyst of the deep infratemporal fossa.

The authors report a case of an epidermal inclusion cyst found in the deep infratemporal fossa 12 years after the patient sustained blunt trauma to that region. Posttraumatic epidermal inclusion cysts are rare and occur mainly in the fingers, palms, and soles. Introduction of the epidermal elements into the dermis during the trauma is thought to be the cause. This case is rare in presentation, with few reports in the English literature that describe an epidermal inclusion cyst in the deep infratemporal fossa. Review of the English literature disclosed no other cases of epidermal inclusion cyst after blunt trauma involving the deep infratemporal region.

Femur-Vastus Intermedius-Anterolateral Thigh Osteomyocutaneous Composite Chimeric Free Flap: A New Free Flap for the Reconstruction of Complex Wounds

Among the many bone and muscle flaps described in literature, several have stood the test of time and come forward as the preferred donor sites. Each has its own advantages and disadvantages. Yet another bone flap that has never been described in literature is introduced here. This is the vascularized femur bone flap based on the periosteal blood supply from the overlying vastus intermedius muscle. The vastus intermedius muscle free flap has the advantage of easy harvest, consistent vascular anatomy, long pedicle with large-caliber vessels, easy patient positioning, two-team approach, large surface area, minimal thickness, minimal donor site morbidity, and minimal functional loss. In this report, the femur-vastus intermedius-anterolateral thigh osteomyocutaneous chimeric free flap based on the descending branch of the lateral circumflex femoral artery is used in the reconstruction of a complex composite defect of the lower extremity.

Free segmental vastus lateralis muscle flap for reconstruction of recalcitrant defects of the cleft hard palate.

INTRODUCTION Large recalcitrant defects of the anterior palate due to clefting are difficult to close with local tissues. In some cases distant tissue transfer may be the only option. Free segmental vastus lateralis muscle with its long high-caliber pedicle and low donor-site morbidity may be a good option. PATIENT/METHOD An 8-year-old girl with bilateral cleft lip and palate was evaluated for a defect in the anterior hard palate. She had four failed palate closures resulting in a 3.2 × 2.8 cm defect with severely scarred surrounding palatal tissues and severely hypernasal speech. A vastus lateralis muscle with a 7-cm pedicle was prepared. Only a 5 × 4 × 1 cm segment of muscle was harvested based on segmental motor innervations, thus sparing 90% of the remaining muscle. Vessels were anastomosed to the facial artery and vein through a facial tunnel. The flap was directed into the palatal defect via the right alveolar cleft and sutured in a fashion to prevent dehiscence and fistulization. RESULTS The surface of the flap mucosalized over an 8-week period. The defect was completely closed. The speech markedly improved. There was no donor-site morbidity. CONCLUSION Free segmental vastus lateralis muscle offers easy harvest, a two-team approach, long pedicle length, a highly vascularized flap, and no functional loss.

How to Kill a Flap: Munchausen Syndrome — A Silent Trap for Plastic Surgeons

Munchausen syndrome (MunS) is described as a factitious disorder, where the patient presents with recurrent self-inflicted illnesses or injuries, for the purpose of assuming the sick role and gaining medical attention. Even though MunS can be a rare disorder, a plastic surgeon must always stay cautious for alarming symptoms that can point to it, so as to avoid involving the patient in unnecessary operations and procedures, as well as wasting the institute’s resources. In this report we describe a case with MunS who underwent flap reconstruction of her hand wound. The case was diagnosed as MunS only after two flaps failed in an unconventional pattern and at unusual time frame during the postoperative period. This is the first case in English literature where a MunS patient creates necrosis in a flap intended to reconstruct the self-inflicted wound.

Versatility of the Perforator-Based Adipose, Adipofascial, and Fasciocutaneous Flaps in Reconstruction of Distal Leg and Foot Defects.

Reconstruction of the distal leg, ankle, and foot is challenging, and local perforator flaps have emerged as valuable options. The aim of the present study was to evaluate the outcomes of local perforator flaps in the distal lower extremity. A total of 14 local perforator flaps were used in 12 patients (9 males [75%] and 3 females [25%], aged 19 to 83 years). The etiologies included 7 motor vehicle accidents (50%), 2 acute burns (14.29%), 2 chronic wounds (14.29%), 1 postburn contracture (7.14%), 1 gunshot wound (7.14%), and 1 malignancy (7.14%). The defects were localized to the mid-leg in 3 cases (21.43%), ankle in 4 (28.57%), calcaneus in 4 (28.57%), and foot in 3 (21.43%). A peroneal artery perforator flap (11 sites [78.57%]) or a posterior tibial artery perforator flap (3 sites [21.43%]) was used. Of the 14 flaps, 8 (57.14%) were fasciocutaneous, 4 (28.57%) were adipofascial, and 2 (14.29%) were adipose. The flap transfers were rotational in 9 cases (64.29%), flipped in 2 (14.29%), propeller in 2 (14.29%), and transcrural in 1 (7.14%). The flap dimensions ranged from 8 cm × 5 cm to 22 cm × 5 cm. Finally, 12 flaps (85.71%) remained viable, 1 (7.14%) had partially sloughed, and 1 (7.14%) had completely died owing to a hypercoagulable state. Overall, 13 flaps (92.86%) had good outcomes after a median follow-up period of 19 (range 12 to 37) months. Perforator flaps in the lower extremity are versatile in terms of size, design, composition, and axis of rotation. They are reliable and safe when used to reconstruct local defects.

Preservation of the Contralateral Abdominal Flap Following Harvest of Unilateral Deep Inferior Epigastric Artery Perforator Flap for Staged Bilateral Breast Reconstruction

Simultaneous bilateral breast reconstruction using two DIEAP flaps is considered as the gold standard. However, the operation is lengthy and requires two plastic surgery teams with high expertise. In cases where the bilateral reconstruction is staged, either another donor area is required or an implant is used, because the unused abdominal tissue is discarded in the first operation. We describe a new technique to preserve the contralateral half of the abdomen for staged bilateral breast reconstruction. This would decrease the operating time significantly especially for teams where there is only a single experienced plastic surgeon.