Tugrul Maral

Effectiveness of human amnion preserved long-term in glycerol as a temporary biological dressing

Human amnion as a temporary biological wound dressing has remained a beneficial and cost-effective means of treating burns in developing countries. The aim of this study was to determine whether human amnion that has undergone long-term preservation in glycerol is an effective biological dressing compared to fresh amnion and glycerol-preserved human skin. Samples of human amnion and skin were preserved in sterile containers of 85% glycerol at 4 degrees C for over a year. Dorsal full-thickness or split-thickness skin wounds were produced in rats. The defects were divided into four areas, each of which was covered with preserved amnion, fresh amnion, preserved skin, or left uncovered as a control. The materials on the wounds were evaluated macroscopically and microscopically after 2, 4, 7, 10 and 14 days. The primary take or adherence of the grafts on full-thickness wounds was evaluated at 4 and 7 days, and material performance was scored based on several macroscopic and microscopic criteria. The bacteria levels reducing effect of the materials were examined by quantitative bacteriology in heavily infected full-thickness scald burn wounds of rats. Qualitative cultures confirmed that the storage conditions the materials were subjected to for over a year were aseptic and that the amnion and skin had maintained their characteristic properties. All materials were found effective on partial-thickness rat wounds as a cover under which re-epithelialization was completed by 7 days. The preserved skin performed better than either preserved or fresh amnion on full-thickness wounds but the performance of preserved amnion was comparable to that of fresh amnion. Glycerol-preserved amnion was found to be as effective as fresh amnion or skin in terms of decreasing bacterial levels in infected rat burn wounds. Amnion stored in glycerol is reliable and effective for a long period of time. Amnion banking could provide an unlimited quantity of biologic dressing for burn treatment at low cost, a factor that is particularly important in developing countries.

The gluteal fasciocutaneous rotation-advancement flap with V-Y closure in the management of sacral pressure sores.

&NA; The sacral region is one of the most frequent sites of pressure sore development, and local flaps in the gluteal region are usually preferred when surgical closure is needed. The authors used the gluteal fasciocutaneous rotation‐advancement flap with V‐Y closure to manage sacral pressure sores in 15 patients. The design was a combination of the classic rotation and V‐Y advancement flap patterns. When the wound was closed, the tension at the distal end of the rotation flap was relieved by flap advancement and the combined rotation‐advancement action was supported laterally with V‐Y closure. A wide skin pedicle was preserved at the inferomedial part of the flap. This pedicle augmented the blood supply to the flap skin and kept the surgical incision small, thus helping to reduce the risk of fecal contamination and associated wound‐healing problems. This flap can also be converted to any design of fasciocutaneous or musculocutaneous V‐Y advancement flap, should such a change be required. The largest defects that were closed with a unilateral rotationadvancement flap and bilateral rotation‐advancement flaps were 12 and 18 cm in diameter, respectively. In 1.5 to 35 months of follow‐up, none of the patients developed wound dehiscence or flap necrosis requiring repeated surgery. This technique is simple, can be performed quickly, has minimal associated morbidity, and yields a good outcome. (Plast. Reconstr. Surg. 109: 2325, 2002.)

The Koebner phenomenon in immunosuppression-related Kaposi's sarcoma.

The Koebner phenomenon has been reported to develop in classic or acquired immune deficiency syndrome-related Kaposis sarcoma (KS). A 12-year-old kidney transplant recipient who developed immunosuppression-related KS showed reoccurrence of lesions in some previously intact incision sites following removal of tumor, suggesting Koebner phenomenon. It is recommended that surgeons be careful when planning surgical interventions in patients with certain skin disorders in which Koebner phenomenon is known to develop.

Fingertip reconstruction using two variations of direct-flow homodigital neurovascular island flaps.

&NA; The fingertip is an extremely intricate area of digital sensibility that plays an important role in fine perception and hand function. Thus, sensate fingertip reconstruction is essential to the recovery of most hand functions. The authors used two methods of direct‐flow homodigital neurovascular island flap coverage to reconstruct distal finger amputations—namely, the triangularadvancement flap technique and the step‐advancement flap method. The authors present their experience with these two variations of direct‐flow homodigital neurovascular island flaps and their use in reconstructing 18 fingertips and 7 proximal amputation stumps. They did not observe flap failure, and they achieved stable, well‐vascularized, appropriate‐thickness skin coverage with good sensory properties in all patients. However, they found that the triangular‐advancement flap technique was easier to plan and perform than the step‐advancement method. Borman H, Maral T, Tancer M. Fingertip reconstruction using two variations of direct‐flow homodigital neurovascular island flaps. Ann Plast Surg 2000;45:24‐30

Skin flap survival after superficial and deep partial-thickness burn injury.

Whether a flap can be raised successfully in a body region that has been subjected to burn injury remains an issue. The aim of this study was to investigate the survival of skin flaps that were elevated after superficial and deep partial-thickness burn injury in a rat model. Sixty-five rats were divided into five groups: Group 1 (N = 15) was the control group, group 2 (N = 10) included rats with superficial partial-thickness burns that had flaps elevated on day 0, group 3 (N = 15) was comprised up of rats with superficial partial-thickness burns that had flaps elevated on day 4, group 4 (N = 10) included rats with deep partial-thickness burns that had flaps elevated on day 0, and group 5 (N = 15) was comprised of rats with deep partial-thickness burns that had flaps elevated on day 4. Caudally based dorsal flaps consisting of skin and panniculus carnosus were elevated in all groups, and the amount of surviving tissue on each flap was quantified. The surviving areas of flaps elevated on postburn days 0 and 4 in superficial partial-thickness burn zones (groups 2 and 3) were larger than those of flaps that were elevated on postburn days 0 and 4 in deep partial-thickness burn zones (groups 4 and 5). The surviving portions of flaps that were elevated on day 4 in superficial partial-thickness burn zones (group 3) were similar to the surviving areas of flaps in the control group (group 1), and were larger than those of all other groups (groups 2, 4, and 5). In this rat model, flaps were elevated in superficial dermal burn zones with successful outcomes. However, raising flaps in deep dermal burn zones was not a reliable method.

Technique for blepharoptosis correction using double- breasted orbicularis oculi muscle flaps

Background:The technique that uses the orbicularis oculi muscle flap to elevate the upper eyelid has become a popular surgical alternative for blepharoptosis. This method is especially effective in cases of severe blepharoptosis with poor levator muscle function. In this technique, the superiorly based orbicularis oculi muscle flap (which is connected to the frontalis muscle anatomically) is advanced and attached to the tarsal plate, thus enabling dynamic elevation of the upper eyelid. However, a temporary period of lagophthalmos occurs with the original method. Although the problem is temporary, it typically lasts 2 to 6 months and may lead to serious eye emergencies. Methods:We describe a modification that eliminates lagophthalmos, which is the main drawback of the original technique. Two orbicularis oculi muscle flaps are created, one superiorly based and one inferiorly based. The inferiorly based flap corresponds to the strip of pretarsal orbicularis oculi that is considered “excess” and is discarded in other methods. Our aim with this modified technique is to preserve as much of the pretarsal part of the orbicularis oculi muscle as possible, and thus enable immediate tight eyelid closure postoperatively and achieve dynamic, powerful eyelid-opening action. Results:We have used this technique in 7 patients (11 eyelids total) during the past 5 years and have achieved favorable results. All 11 operated eyelids showed immediate tight closure postoperatively, as well as dynamic, powerful eyelid-opening action. Conclusion:This operation is a good alternative for patients with severe ptosis who have insufficient levator function and for cases that have recurred after operations with other methods. Local native tissues are used and dynamic correction is achieved with a single incision. The need for intensive eye care is eliminated and there is less risk of corneal damage in the early postoperative period. Above all, this technique yields predictable eyelid-opening action.

Bilateral synchronous primary orbital lymphoma

Extranodal marginal zone B-cell non-Hodgkin’s lymphoma affecting bilateral orbital regions was diagnosed in an 80-year-old man. He was given chemotherapy and external beam irradiation therapy. Two months after treatment, repeat orbital magnetic resonance imaging showed dramatically improved lesions. In this case report, orbital non-Hodgkin’s lymphoma and treatment options are discussed.

PERIORBITAL RECONSTRUCTION USING VARIATIONS OF THE UPPER EYELID FLAP

Tissues that have characteristics identical or similar to periorbital soft tissue are preferred for reconstruction in the eye region. The upper eyelid is part of the periorbital area that provides an ideal reserve of tissue for this purpose, without producing a donor-site deformity. We used the upper eyelid flap with different pedicle designs in various parts of the periorbital region in 21 patients, and achieved favourable results. The flap was medially-based in five, superomedially-based in seven, laterally-based in eight, and superolaterally-based in one. The tissue defects were the result of the excision of tumours in 18 patients, and of injury in three. The defects were located in the upper eyelid in two, the lower eyelid in five, the medial canthus in eight, the lateral canthus in four, and in the neighbouring orbitonasal zones in two. Different sized flaps were used according to the dimensions of the defects, which ranged from about 1 to 8 cm 2 . The upper eyelid flap is versatile, and provides tissue of ideal colour and texture. The procedure can be done quickly in one stage with minimal morbidity.

Reconstruction of the upper portion of the ear by using an ascending helix free flap from the opposite ear

Reconstruction of partial, marginal defects of the ear has been a challenge. The ascending helix free flap based on superficial temporal vessels has been described and used solely to repair nose defects. We used reversed pedicle helical free flap for the repair of a major loss of the upper one-third of the opposite auricle. The method permits the transfer of tissue of the same quality with satisfactory cosmetic result. The equalization of the ears in dimension was accomplished with minimal donor-site deformity.

Wound healing at adaptation zones of skin flaps harvested from acute burned skin

BACKGROUND Early reconstruction of burn defects culminates in more successful results. The wound healing process of the burned skin affects not only the curative phase of the burned area but also result of any reconstructive procedure including the regional flaps. Thus, in this study, we have evaluated the wound healing process at the distal incisions of random-pattern skin flaps prepared from burned dorsal skin of rats. MATERIALS AND METHODS Thermal burn damage was performed with dimensions of 3cm×3cm on Wistar albino rats. In group 1 (n=12), no burn was produced and 3cm×3cm caudally based, random-pattern skin flaps were elevated. In group 2 (n=12), a 5cm×5cm area of partial-thickness thermal damage was produced and after three days a 3cm×3cm random-pattern skin flap was elevated as in group 1 inside the burned skin site. In group 3 (n=12), 3cm×3cm area of partial-thickness thermal damage was produced and after three days 3cm×3cm random-pattern skin flap was elevated. In group 4 (n=12), 3cm×3cm area of partial-thickness thermal damage was produced and after three days a 3cm×3cm random-pattern skin flap was elevated at the distal margin of the burned area. The flaps were adapted to the donor sites in all groups. The histopathological evaluation was done and hydroxyproline levels were measured. RESULTS There were no significant differences between groups regarding presence of epithelialization, myofibroblast numbers, and collagen texture (p>0.05). Neovascularization level was significantly higher in group 2 than the other groups (p<0.05). There were no statistically significant difference among the hydroxyproline levels in all four groups (p>0.05). CONCLUSION The preference of the incision site in a burn zone while designing a flap during the acute burn period was proposed to possess no difference in terms of wound healing in an animal model.