Tekin Simsek

Delay in neurovenous flaps: Experimental and clinical experience

The objective of this study was to examine the effects of the standard surgical delay in the flaps based on the cutaneous branches of the vascular axis around a superficial sensory nerve. The delay procedure was experimentally tested in rats and subsequently used in patients. In the experimental study, the survival of a delayed inferior epigastric neurovenous flap was compared with that of a nondelayed inferior epigastric neurovenous flap. One type of clinically applicable delay pattern (standard bipedicled technique) was employed. A 3 × 3 cm flap was raised in 20 female Wistar rats assigned randomly to 2 groups. Each group consisted of 20 flaps. The standard bipedicled delay pattern increased the percentage survival of the delayed inferior epigastric neurovenous flap. The survival percentage of the delayed flaps was 59.8 ± 185.0 (P < 0.5). The histologic findings of the skin revealed that our delay procedure enhanced the perfusion of the flap by dilating the arterial network. Stimulated by our experimental findings, we used the island bipedicled surgical flap delay or combined strategic-standard delay in the distally pedicled sural flap successfully on 9 cases.

Finger pulp reconstruction with free dorsoulnar artery perforator (DUAP) flap.

Finger pulp is a common site for hand injuries, and pulp reconstruction is significantly important for optimal handling and sensation. Ideal substitute must provide matching texture, tenacity, and slim subcutaneous fat. This article presents six cases in which fingertip and finger pulp reconstruction were performed via free dorsoulnar artery perforator (DUAP) flap. All flaps survived and all patients healed uneventfully without any complications by the end of at least 3 months follow-up. Free DUAP flap has proved to be a suitable substitute for pulp reconstruction with its thin structure, minimally morbid donor site which is also close to the trauma zone, and possibility for neurotization. It can be especially favorable when splitting the surgical team for a glabrous flap harvest from the foot is not possible.

Giant fibrolipoma with osseous metaplasia on the thigh

Fibrolipomas are characterised by fat lobules embedded in perivascular oval fibrocytes and thick bundles of collagen. Actively growing superficial fibrolipomas rarely display a pedunculated protrusion and, thus, cosmetic and functional problems are uncommon. We present an exceptional case. While trauma and ischaemia can lead to fibrosis and dystrophic calcification in fibrolipomas as late sequelae, osseous and cartilaginous metaplasia can infrequently manifest after a long, chronic persistence. Further, depending on the chronic irritation, ulcerated wounds may develop on the surface, and these can be clinically confused with malignancy. In this article, we present a case of a pedunculated giant fibrolipoma manifesting metaplasic changes in its structure.

Reconstruction of Extensive Orbital Exenteration Defects Using an Anterolateral Thigh/Vastus Lateralis Chimeric Flap

Abstract Neglected malignant tumors within the orbital region can invade the eyeball, extraocular muscles, and bone substance surrounding the eye. Such patients require orbital exenteration, which may involve extraocular skeletal structures (even exposing paranasal sinuses), resulting in 3-dimensional defects requiring reconstruction. This study presents our experience with anterolateral thigh vastus lateralis (ALT/VL) chimeric free flaps for the reconstruction of extensive orbital exenteration defects involving various paranasal sinuses. Between 2012 and 2016, 4 patients with extensive 3-dimensional orbital defects with sinus involvement were treated using the ALT/VL chimeric flap. The ALT component (117–170 cm2) was used to resurface the cutaneous defect while the VL component (105–243 cm3) was used to obliterate the cavitary defect. The flaps were all based on the common descending pedicle, and branches to separate components were individually dissected. Recipient vessels were in the neck region, to which the donor pedicles were passed through a tunnel for anastomosis. All cavitary and surface defects were simultaneously reconstructed via the ALT/VL chimeric flap. Within an average of 17 months, no complications associated with flap surgery were observed. One patient received postoperative adjuvant radiotherapy with no complications. With its separate components supplied by a common vascular pedicle, the ALT/VL chimeric free flap allows the surgeon to conveniently reconstruct separate spatial and volumetric defects resulting from extensive orbital exenteration.Neglected malignant tumors within the orbital region can invade the eyeball, extraocular muscles, and bone substance surrounding the eye. Such patients require orbital exenteration, which may involve extraocular skeletal structures (even exposing paranasal sinuses), resulting in 3-dimensional defects requiring reconstruction. This study presents our experience with anterolateral thigh vastus lateralis (ALT/VL) chimeric free flaps for the reconstruction of extensive orbital exenteration defects involving various paranasal sinuses.Between 2012 and 2016, 4 patients with extensive 3-dimensional orbital defects with sinus involvement were treated using the ALT/VL chimeric flap. The ALT component (117-170 cm) was used to resurface the cutaneous defect while the VL component (105-243 cm) was used to obliterate the cavitary defect. The flaps were all based on the common descending pedicle, and branches to separate components were individually dissected. Recipient vessels were in the neck region, to which the donor pedicles were passed through a tunnel for anastomosis.All cavitary and surface defects were simultaneously reconstructed via the ALT/VL chimeric flap. Within an average of 17 months, no complications associated with flap surgery were observed. One patient received postoperative adjuvant radiotherapy with no complications. With its separate components supplied by a common vascular pedicle, the ALT/VL chimeric free flap allows the surgeon to conveniently reconstruct separate spatial and volumetric defects resulting from extensive orbital exenteration.

Comparison between Flexible Collagen and Vein Conduits Used for Size-Discrepant Nerve Repair: An Experimental Study in Rats

Primary nerve repair is the gold standard in nerve reconstruction. When primary repair is not possible for injured nerves, conduit-assisted repair methods are frequently used. As conduits, autologous vein segments or allogenic biodegradable products can be used. However, their effectiveness when used in a nerve defect where a size discrepancy exists has not been compared. In this study, either a vein graft or a synthetic collagen conduit was used to bridge 10-mm defects between size-discrepant tibial and peroneal nerves in a rat model. After 90 days, nerve regeneration was evaluated using electrophysiological and histological methods. It can be concluded based on the results of this study that bridging a 10-mm nerve gap with synthetic collagen conduits and autologous vein grafts yielded similar results in small-to-large nerve coaptations, with the vein graft being slightly more effective.

Simultaneous cheek and lower eyelid reconstruction with combinations of local flaps.

Abstract Cheek defects are common facial defects, especially after tumor ablation. Although primary repair yields the best aesthetic outcome, wide defects require flap resurfacing. Among the flap techniques, the cervicofacial rotation/advancement flap is one of the most common. In cases with eyelid involvement, it is very unlikely that a local flap would single-handedly resurface the defect and additional flaps must be used. This article presents our clinical experience with 14 patients with cheek defects for whom cervicofacial rotation/advancement flaps were used. In 3 of the 14 patients, local flaps that include the laterally based Tripier flap, the Fricke flap, the nasojugal flap, and the median forehead flap were combined with the cervicofacial flap to reconstruct the lower eyelid defects in accordance with the principle of individually reconstructing different anatomic subunits. All infraorbital defects were resurfaced with residual cheek and cervical skin with a good color and texture match. In patients whose eyelids were intact, no malposition was observed. Posteriorly based cervicofacial rotation/advancement flaps offer a very reliable and convenient method for resurfacing infraorbital and medial cheek defects. When a lower eyelid defect is also present, its individual reconstruction as a separate facial subunit needs to be considered using a combination of smaller local flaps.

Multiple Subungual Pyogenic Granulomas Following Levothyroxine Treatment.

Abstract Pyogenic granulomas are benign vascular lesions that can result from a large number of etiological factors. Drugs are one etiological factor involved in pyogenic granuloma development. In this study we present our experience of multiple pyogenic granulomas following levothyroxine administration suggesting that levothyroxine hormone replacement therapy might play an important role in the formation of pyogenic granuloma. We also reviewed the literatures regarding drug-induced pyogenic granulomas.

Versatility of the pinwheel flap to reconstruct circular defects in the temporal and scalp region

Abstract The pinwheel flap technique involves raising four small rotation flaps, which are 90° apart from each other and converge into a defect in their centre. It is suitable for resurfacing defects of the scalp, which offers limited skin mobility. It may also be used for certain circular skin defects on the hairless temporal region. This study first re-formularised the original description of this flap technique via a laboratory study. Thanks to a new smaller flap design, closure was achieved with a lesser scar. Afterwards, the technique was used on the 14 patients who had circular skin defects of the temple and scalp. Defect diameters and resultant scar lengths were recorded. When the new design was used, scarring required for defect closure was less than half of that required for the original design. Thus, it was easier to avoid distortion to the anatomical subunits such as eyebrows and hairline. It is believed that this technique is quite appropriate for closing circular defects of scalp up to 50 mm, and temporal defects up to 40 mm. Also, Z-plasties can be added to the design when needed to increase flap rotation and decrease skin distortion.

A simple concept for covering pressure sores: wound edge-based propeller perforator flap†

We present a new surgical modification to allow propeller perforator flaps to cover pressure sores at various locations. We used a propeller perforator flap concept based on the detection of newly formed perforator vessels located 1 cm from the wound margin and stimulated by the chronic inflammation process.

Accordion-style pedicle suspension in inferocentral pedicled mammoplasty

Abstract Objective: In breast reduction surgery, while the primary objective may appear to be decreasing the breast volume, the ultimate goal is to achieve symmetrical, appealing, and sustainable breast cosmesis. To circumvent late-term ptosis following inferior pedicle mammoplasty, methods such as pedicle suspension to the ribs, support with dermal flaps and grafts, and the use of some alloplastic materials have been proposed. This paper presents a method of folding and fixing the inferocentral pedicle on itself and the underlying pectoral fascia. Methods: Inferocentral pedicled, inverted T-scar reduction mammoplasties were performed on 50 patients from June 2009 to June 2014. The inferocentral pedicle, which was kept narrow and long, instead of the conventional inferior-based pyramidal design, was folded over its de-epithelialised surfaces in an accordion fashion and sutured. The confection was then sutured to the pectoral fascia by its lateral and superior borders for long-term preservation of breast moulding. Results: In inferocentral breast reduction, the quest for a method that achieves appealing and lasting pyramidal breast shape continues. Conclusions: This technique is regarded as a simple and effective method for achieving good short- and long-term results for patients being considered for moderate and advanced breast reduction.